Critical Care Flashcards
1
Q
pneumothorax
A
- air in the pleural space (spontaneous primary (simple) w/o underlying dz (healthy), spontaneous reupture of subpleural blebs, MC in tall, lean men, 50% recurrence in 2y
- secondary (complicated) → underlying lung dz (MC COPD), asthma, ILD, neoplasm, CF, TB, life threateing
- traumatic - iatrogenic
- sxs: ipsilateral chest pain, sudden onset, dyspnea, cough, dec/absent tactile fremitus, mediastinal shift toward affected side, dec breaht sounds over affected side, hyperresonance
- dx: CXR confirms dx, visceral-pleural line
- tx: if small and asxatic, observe 10d +/- small chest tube; large +/- sxs → O2 w/ chest tube; secondary → chest tube drainage; repeat CXR daily until resolved
2
Q
pulmonary embolism RF and sxs
A
- thrombus embolizes to pulm vasc tree via RV and pulm artery → causes cor pulmonale (severe)
- MC site → distal to bifurcation of main pulm artery in main lobar, segmental, or subsegmental branches of pulm a; saddle → bifurcation of main pulm a
- incidence = M>F
- RF: age >60y, malig, prior hx, hypercoag, prolonged immobilization or bed rest, long-distance travel, cardiac dz, obesity, nephrotic syndrome, major surg or major trauma, preg, E use (OCP)
- Virchows triad: hypercoag, venous stasis, endothelial injury
- sxs: dysp (at rest or with exert), pleuritic chest pain (worse with insp), cough, calf or thigh pain or swelling, wheezing, hemoptysis, syncope
- signs: tachypnea, tachycardia, rales, dec breath sounds, accentuated pulm component of S2, JVD, fever
- signs of RVHF: hypoTN and JVD, R-sided S3, parasternal lift, cyanosis
3
Q
pulmonary embolism diagnostics and tx
A
- dx: CXR, D dimer (if low clinical suspicion - do first), EKG (tachy and non specific ST and T wave changes - <10% shows S1Q3T3), + CT pulm angiogram w/ contrast (GOLD STANDARD), VQ scan, normal CXR required prior → test of choice in pregnancy, contrast allergy, and pts with renall insuff, doppler US of lower extrem, Increased A-a gradient, ABG shows resp alkalosis
- tx: O2, hemodynamically unstable (IVF, vasopressors: NE), anticoag
- prognosis: recurrenc common
- poor prognostic factors: hyponNa, elevated lactate, leukocytosis, age >65
4
Q
coma
A
- depressed level of consciousness to extent that pt is completely unresponsive to any stimuli
- causes: structural brain lesions, global brain dysfn (met or systemic disorders), psychiatric causes
- Glasgow coma scale
- if breathing on own, brainstem is functioning
- Eye opening (4; none, to pain, to voice, spont), verbal response (5; none, incomp, inappropriate, approp but confused, approp and oriented), motor response (6; none, decerebrate, decorticate, withraws from pain, localizes pain stim, obeys commands)
5
Q
criteria for brain death versus persistent veg state
A
- irreversible absence of brainstem fn (brain death): unresponsive, panea despite adequate O2 and vent, no brainstem reflexes (pupils, caloric, gag, cornea, doll’s eyes)
- persistent veg: completely unresponsive but eyes are open and appear awake, may have randome head or limb movements
6
Q
ARDS
A
- acute hypoxemic resp failure following systemic or pulm insult w/o evidence of hrt failure, effects of inc pulm fluid same as cardiogenic pulm edema, but the cause is different
- RF: sepsis (MC) dt PNA, urosepsis, wounds, aspiration, severe trauma, fxs, acute pancreatitis, multiple or massive transfusions, drug OD/toxins, intracranial HTN, cardiopulm bypass
- sxs: rapid onset dyspnea
- signs: labored breathing, tachyp, tachycard, retractions, crackles
- progressive: hypoxemia, unresponsiveness to O2, diff ventilating dt high peak airway pressures
- dx: CXR (diffuse bl pulm infiltrates) w air bronchograms), resp alkalosis → resp acidosis dt tachypnea; PCWP low, bronchoscope w bronchoalveolar lavage
- tx: mech vent w PEEP
7
Q
acute resp failure
A
- resp dysfn resulting in abnl O2 or vent severe enough to threaten fn of vital organs
- sxs: dyxpnea, HA, anxiety
- signs: cyanosis, peripheral and conjunctival hyperemia, restlessness, confusion, tachypnea, bradycardia, or tachycardia, HTN, tremor, asterixis, papilledema
- dx: ABC PO<60, PCO2 >50
- tx: tx underlying cause, resp support, ventilator support (NPPV, BiPAP, tracheal intubation), supportive care
8
Q
upper GI bleed
A
- bleeding originates proximal to lig of treitz
- ddx: peptic ulcer, esophageal varices, gastric bleeding from portal HTN, gastritis, AVM, tumor, Mallory-Weiss tear
- RF: NSAIDs, ASA, anticoag, antiplatelet, ETOH, prev GI bleed, liver dz, coagulopathy
- sxs: Hematemesis (blood or coffee ground), Melena, hematochezia (massive upper GI bleed)
- signs: orthostatic HoTN, tachycard, abdominal TTP
- dx: type and screen, Hgb, plt count, coag studes, liver enzymes, albumin, BUN/Cr, NG lavage + for blood = confirmatory
- endoscopy once stabilized (give erythromycin before exam), abx prophylactically for cirrhotics
- tx: supportive (NPO, IV access, O2, IVF, IV PPI until confirmation of cause of bleeding, consult GI and interventional radiology or surg, tx underlying cause, surg (duodenotomy or gastroduodenotomy, ligation of bleeding)
9
Q
lower GI bleeding
A
- bleeding from site distal to ligament of Treitz
- ddx: diverticulosis (MC), angiodysplasia, colitis, colon CA, proctitis
- sxs: hematochezia, melena (seen w/ bleeding from R colon or small intest), orthostatic HoTN or shock
- dx: CBC, liver test, coag studies, Hgb q2-8hrs, BP, O2, EKG, colonoscopy (only if upper bleed ruled out), CT or mesenteric angiography (requires active bleed to identify source)
- tx: supportive care (O2, IV, fluid and blood resuscitation, managment of coagulopathies, antiplatelets, anticoags)
10
Q
Abdominal pain high risk features
A
- age >65, immunocompromised, alcoholics, CV dz, major comorbidities (cancer, diverticulosis, gallstones, IBD, pancreatitis, renal failure, prior surgery or recent GI instrumatation, ealry preg
- pain characteristics: sudden onset, maximal at onset, pain with subsequent vomiting, constant pain of <2 d duration
- exam findings: tense or rigid abdomen, involunatry guarding, signs of shock
- life threatening causes: bowel obstruction, mesenteric ischemia, acute pancreatitis, and myocardial infarction
11
Q
abdominal pain locations and causes: RUQ, epigastric, LUQ
A
- RUQ:
- colonic: colitis, diverticulitis
- Biliary: cholesystitis, cholelithiasis, cholangitis
- hepatic: abscess, hepatitis, mass
- pulm: PNA, embolus
- renal: nephrolithiasis, pyelonephritis
- primary test of choice: US
- epigastric:
- biliary: cholecystitis, choleltihiasis, cholangitis
- cardiac: MI, pericarditis
- vascular: aortic dissection, mesenteric ischemia
- pancreatic: mass, pancreatitis
- gastric: esophagitis, gastritis, PUD
- primary test of choice: CT
- LUQ
- cardiac: angina, MI, pericarditis
- vascular: aortic dissection, mesenteric ischemia
- pancreatic: mass, pancreatitis
- renal: nephrolithiasis, pyelonephritis
- gastric: esophagitis, gastritis, PUD
12
Q
abdominal pain locations and causes: periumbilical, RLQ, suprapubic, LLQ
A
- periumbilical
- colonic: early appy
- vascular: aortic dissection, mesenteric ischemia
- gastric: esophagitis, gastritis, PUD, small bowel mass, obstruction
- RLQ:
- colonic: appy, coliitis, diverticulitis, IBD, IBS
- renal: nephrolithiasis, pyelonephritis
- Gyn: ectopic, fibroids, ovarian mass, torsion, PID, endometriosis
- primary test of choice: CT with con
- suprapubic
- colonic: appendicitis, colitis, diverticulitis, IBD, IBS
- renal: nephrolithiasis, pyelonephritis, cystitis
- Gyn: ectopic, fibroids, ovarian mass, torsion, PID, endometriosis
- primary test of choice: US
- LLQ
- colonic: colitis, diverticulitis, IBD, IBS
- renal: nephrolithiasis, pyelonephritis
- Gyn: ectopic, fibroids, ovarian mass, torsion, PID, endometriosis
- primary test of choice: CT with oral and IV con
13
Q
glaucoma
A
- increased IOP with optic nerve damage
- dx: visual field testing, opthalmoscopy, gonioscopy (determines cause), tonometry to measure IOP
- Normal IOP: 10-21 mmHg
14
Q
acute angle closure glaucoma
A
- peripheral iris blocks outflow of aqueous humor from anterior chamber, associated with papillary dilation
- RF: old, asian, hyperopes
- sxs: sudden dull or severe eye pain (bilateral), worse in dark rooms, blurry vision, frontal HA, tearing, N/V, sweating
- PE: conjunctival hyperemia, ciliary flush, cloudy or hazy cornea, midposition or middilated and nonreactive pupil
- dx: penlight test - project from lateral to nasal, will project shadow on nasal side; tonometry (markedly increased IOP), cornea edematous
- tx: immediate referral, first line topical agents = BB, alpha antag (brimonidine, apraclonidine0, prostaglandin analogues (latanoprost)
- topical miotic: pilocarpine
- adjunct cycloplegic agents: IV acetazolamide, IV mannitol
- laser iridotomy (definitive)
- DO NOT administer mydriatics to these pts
15
Q
primary adrenal insufficiency (addison dz)
A
- chronic adrenocortical insufficiency
- adrenal gland does not produce cort, aldosterone, or sex hormones (retain no sodium), primary adrenal failure from autoimmune adrenalitis
- sxs: hyperpig dt increased ACTH, MSH (POMC), anorexia, abdominal pain, N, V, wt loss, lethargy, confusion, psychosis, weakness, malaise, postural HoTN, dizziness, salt craving
- signs: hypotension (orthostasis)
- dx: electrolytes (hyponat, hyperkalemia, hypoglycemia, hypercalcemia, elevated SCr), low serum cort, high ACTH, low aldo and high renin
- cosyntropin test = definitive (cort will not elevate sufficiently → test also known as astandard ACTH test
- tx: daily oral steroids (hydrocort, prednisone), daily fludrocort (mineralocort)
