Critical Care Flashcards
[diagnosis]
72/M with COPD, CHF and back pain. On oxycodone and morphine treatment
unarousable, discovered multiple intake of morphine
BP 130/80, HR of 90/min, O2 sats 90% pinpoint pupils
Dx: Acute hyperbaric respiratory failure secondary to opiate overdoe
Initial test: ABG
Appropriate management: reverse effects of opiates, require intubations
[Type of Respiratory Failure]
PaO2 <55-60 mmHg
alveolar flooding, intrapulmonary shunt
Type I (flood)
Pulmonary edema, pneumonia, alveolar hemorrhage, ARDS
[Type of Respiratory Failure]
pCO2 >45-50mmHg
Diminished CNS drive to breathe, reduced neuromuscular strength, increased load to respiration
Type II (cant eliminate CO2)
[Type of Respiratory Failure]
perioperative respiratory failure, atelectasis
Type III Athreelectasis
[Type of Respiratory Failure]
hypoperfusion of respiratory muscles in shock
Type IV SHOCK!
[Cause of hypoxemia]
Increased A-a gradient that is correctable with O2 can be caused by?
This is V/Q mismatch
- Airway disease
- Interstitial lung disease
- Alveolar disease
- Pulmonary vascular disease
[Cause of hypoxemia]
Increased A-a gradient that is not correctable with O2 can be caused by?
This is a form of R-L shunt
- Intracardiac shunt
- Vascular shunt within lungs
[Cause of hypoxemia]
Normal A-a gradient that has increased PaCO2
This is hypoventilation
- Decreased respiratory drive
- Neuromuscular disease
[Cause of hypoxemia]
Normal A-a gradient that has a normal PaCO2
Low FiO2 (high altitude)
What is the parameter for ventilation?
PaCO2
How will you correct hypercarbia?
increase the minute ventilation or increase RR
How will you correct hypoxemia?
increase FiO2 or increase PEEP
[diagnose]
46M currently admitted developed progressive dyspnea and hypoxia 84%
High pitch crackles, CXR diffuse bilateral infiltrates
ABG: pH 7.3 pCO2 50, HCO3 19, PO2 60 at 10lpm
Dx: ARDS
Next step: Intubate
What is the diagnostic criteria for ARDS?
Berlin Criteria
In Berlin Criteria,
what is the CXR finding suggestive of ARDS?
Bilateral alveolar or interstitial infiltrates not fully explained by effusion, consolidation or atelectasis
In Berlin Criteria, what is the cut-off value for left atrial hypertension?
PCWP <18 mmHg
What are the PF ratio of severity in Berlin Criteria?
PF is:
Severe: <100
Moderate: 100-200
Mild: 200-300
What are the components of Berlin Criteria?
- Acute onset
- Ratio of PaO2/FiO2
- Diffuse bilateral infiltrates in CXR
atrial hypertension - Swan-Ganz pressure <18 mmHg
What is the best management MV management for ARDS?
- Low tidal volume 6mL/kg of predictive body weight
What is the MV management for ARDS?
- TV 6mL/kg
2. PEEP 12-15mmHg
Early muscular blockade using this drug is recommended in the first 48 hours?
Cisatracurium besylate
What keeps the alveoli open in ARDS?
PEEP
[diagnose]
57/M with CHF presents at the Er with progressive dyspnea.
PE: 68/50 140 bpm, elevated JVP, bilateral crackles, cold clammy extremities
Dx: Cardiogenic shock
Urgent Step: fluid resuscitation
First line vasopressor: NE
Inotrope DOC: Dobutamine
What is the cutoff lactate value for lactate?
> 1.5 mmol/L
What are the components of shock state?
- Systemic arterial hypotension
- Tissue hypoperfusion
- Hyperlactatetemia
[type of shock]
2DE: Normal cardiac chambers, preserve contractility
Distributive shock
Normal or High CO
[type of shock]
2DE: Small cardiac chambers and normal or high contractility
Hypovolemic shock
Low CO
LOW CVP
[type of shock]
2DE: large ventricle, poor contractility
Cardiogenic
Low CO
High CVP
In circulatory shock,
what is the second line vasopressor?
Epinephrine
First line: NE
DO NOT USE DOPAMINE
In circulatory shock,
What is the fluid resuscitation of choice?
Crystalloid solution
Infuse 300 to 500 mL in 20-30 minutes
How will you manage acute CHF?
- Diurese - furosemide
- Morphine
- Nitrates
- Oxygen
- Position, sit upright
[How will you manage this case?]
Shock, hypoperfusion, CHF
acute pulmonary edema
- Lasix (Furosemide) 0.5 to 1mg/kg
- Morphine IV 2 mg
- Oxygen
- Nitroglycerin, NE or Dopa
- Dobutamine 2 to 20 ug/kg
What is the ACEi for acute pulmonary edema
Captopril
[How will you manage this case?]
Low CO shock, systolic BP greater than 100?
Give Nitroglycerin 10 to 2 ug/min IV
[How will you manage this case?]
Low CO shock, Systolic BP 70 to 100 mmHg, No signs of shock?
Dobutamine 2 to 20 ug/kg per minute IV
[How will you manage this case?]
Low CO shock, Systolic less than 100mmHg, with signs of shock?
NE 0.5 to 30ug/min IV or
Dopamine 5 to 15 ug/kg/min
Cite the SIRS criteria?
SIRS
Temp >38, or <36 RR >20 HR >90 WBC >12 Leukopenia <4000 or 10% bands
Arterial hypotension is defined as
SBP <90
MAP <60
Changes in SBP from baseline >40
What is the criteria for septic shock?
- Infection
- Vasopressor needed to maintain MAP >/65
- Serum lactate >2 despite resuscitation
Sepsis is diagnosed when…
- Suspected infection PLUS
2. More than 2 in SOFA points
What are the most common gram positive bacteria that cause CAP?
- S. aureus
2. S. pneumoniae
What are the most common gram negative bacteria that cause CAP?
- E. coli
- Klebsiella
- P. aeruginosa
[According to Surviving Sepsis]
the recommended fluid resuscitation is ___
30cc/kg in the first 3 hours, crystalloids
[According to Surviving Sepsis]
the recommended vasopressor is?
NE then Epi
Then add vasopressin to taper NE
AVOID DOPA
[According to Surviving Sepsis]
the recommended antibiotics?
vancomycin + tapimycin (avoid double coverage)
[According to Surviving Sepsis]
the only transfuse when the Hgb is ___ in the absence of acute bleeding and MI
Hgb <7
[According to Surviving Sepsis]
what is the recommended TV
6mL/kg
[According to Surviving Sepsis]
what is the recommended plateau pressure
30cm H20
[According to Surviving Sepsis]
what is the target MAP
MAP 65 mmHg
