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YEAR 4 ACC ME > Critical care > Flashcards

Critical care Flashcards

1
Q

Admission criteria for ICU (2)

A

1) Reversible condition

2) Good functional capacity

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2
Q

Scoring systems in ICU (3)

A

1) APACHE
2) SAPS
3) Mortality prediction model

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3
Q

Levels of care in ICU (0-3)

A

0 - pt needs met on normal ward
1 - risk of deterioration, support of critical care team
2 - HDU (high dependency unit) - single failing organ support, post-op care
3 - ICU, resp support, support of at least 2 organs

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4
Q

7 indications for sedation

A

1) Analgesia
2) Anxiety
3) Dyspnoea
4) Mechanical ventilation
5) Facilitate nursing care
6) Decrease oxygen consumption
7) Delirium

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5
Q

5 main drugs used for sedation (& examples of each)

A

1) Opioids - morphine, fentanyl, femifentanil, alfentanil
2) Benzos - midazolam, lorazepam, diazepam
3) Propofol
4) Haloperidol (dopamine antagonist)
5) Alpha 2 agonists - clonidine, dexmedetomidine

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6
Q

Amnesic & analgesic properties of sedatives

A 
Opioids - analgesic but not amnesic 
Benzos - amnesic 
Proprofol - amnesic but not analgesic 
Haloperidol - amnesic 
Alpha 2 agonists - amnesic + analgesic
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7
Q

Propofol
Mechanism of action
Effect on resp system
Effect on cardio system

A

Facilitate GABA transmission
RESP:
1) Resp depression - reduced tidal volume + increased RR
2) CO2 curve to right
CARDIO:
1) Hypotension due to vasodilation, bradycardia, reduced contractility

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8
Q

What is ARDS?
Severity scale
4 Causes

A

Non-cardiogenic pulmonary oedema - damaged alveoli = leakage of fluid across alveolar capillary membrane
Severity by PaO2/FiO2 ratio (arterial O2 is less than inhaled = failure of lung to transport into blood):
Mild <300
Moderate <200
Severe <100

Causes:

1) Sepsis
2) Pneumonia
3) Trauma
4) Iatrogenic - transfusion, marrow transplant

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9
Q

ARDS

  • Sx 5
  • diagnostic criteria 3
A

1) Cyanosis
2) Tachypnoea
3) Tachycardia
4) Peripheral vasodilation
5) Bilateral fine inspiratory crackles

1) acute
2) cxr = bilateral oedema
3) ABG = reduced PaO2/FiO2

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10
Q

ARDS

- management

A

1) Mechanical ventilation
2) Avoid fluid overload
3) Severe - prone, neuromuscular blockade

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11
Q

What is colonisation?

A

presence of bacteria without causing infection

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12
Q

What colour do gram-positive & gram-negative bacteria stain?

A 
POSITIVE = PURPLE 
NEGATIVE = PINK
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13
Q

MRSA is sensitive to (5)

A

1) Vancomycin
2) Telcoplanin
3) Linezolid
4) Co-trimoxazole
5) Ciprofloxacin

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14
Q

How to remember gram-positive cocci

How to remember gram-positive bacilli

A

+ COCCI:
strep, staph, Lactococci, Viridans, Enterococci = LOVE

+ BACILLI:
Actinomyces, Bacillus, Clostridium, Connybacterium, Listeria (ABC - cl)

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15
Q

How to remember gram negative cocci

How to remember gram negative bacilli

A
  • COCCI
    Neisseria (ne = neg), moraxella
  • BACILLI
    most end in ella (shigella, klebsiella, legionella)
    Flew helicopter over camp, got water-borne diarrhoea, went to hospital = helicobacter, campylobacter, e.coli, vibrio, haemophilus, pseudomonas
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16
Q

Abx treatment for c diff

A

Metronidazole/vancomycin

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17
Q

What 3 main issues occur in post-critical care syndrome?

A

1) ICU-acquired weakness - breathing, muscle wasting, joint stiffness
2) Brain dysfunction - memory, attention, problem solving
3) Mental health problems - PTSD, insomnia, depression

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18
Q

Mental capacity act
2 stage test
4 ways to confirm capacity
5 principles of MCA

A

1) Impairment of mind/brain?
2) Does it affect ability to make specific decision?

1) understand
2) retain
3) weigh up
4) communicate decision

1) presume capacity
2) support decision making
3) not lack capacity just because decision unwise
4) best interests
5) least restrictive option

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19
Q

Is an advance statement/advance decision legally binding?

A

Advance statement - NO

Advance decision - YES, must be in writing, signed & witnessed

20
Q

What are 5 different reasons for futility & withdrawing treatment?

A

1) Physiological eg. giving adrenaline to hypotensive patient & no response
2) Benefit-centred
- quantitative: failed in last x times
- qual: QoL below threshold
3) Cost-based
4) Imminent demise - treatment won’t change fact that they will die
5) Lethal condition - won’t be affected by treatment & will die

21
Q

What 4 drugs are given at end of life

A

1) Morphine
2) Anti-emetic
3) Hyoscine Butylbromide
4) Midazolam

22
Q

What is the definition of death?

A

Irreversible loss of consciousness + irreversible loss of capacity to breathe

23
Q

How do you diagnose neuro death? (3)

A

1) Fulfilment of preconditions
- unconscious + apnoeic + mechanical ventilation
- irreversible brain damage of known aetiology
2) Exclusion of reversible contributions to state of apnoeic coma eg. drugs, cord injury, neuromuscular weakness
- nerve stimulator
- period of observation to allow drug elimination
- antagonist administration
- plasma analysis
- cerebral angiography
3) TWICE demonstrate coma, apnoea, absence of brainstem reflex activity
- pupillary constriction (CN 2 & 3)
- blinking (CN 5 & 7)
- eye movement (CN 3,4,6,8)
- response to painful stimuli (CN 5 & 7)
- gag reflex (9 & 10)
- cough reflex (10)
- apnoea test

24
Q

How do you diagnose cardiac death? (4)

A

After 5 mins asystole

1) loss of circulation - absence of pulsatile flow on arterial line/echo
2) absence of pupillary reaction
3) motor response to corneal stimulation
4) supra-orbital pressure

25
Q

What are the 2 types of organ donation & how do their processes differ?

Liver & kidneys have a higher rate of non-function in…

Warm ischaemic time for:
liver
kidney & pancreas
lung

A

1) After brain stem death
- diagnosis –> optimise –> mobilise team –> retrieval
2) After cardiac death
- mobilise team –> wait for death –> diagnose –> retrieval

Organ donation from circulatory death

<30mins
<60min
<90min

26
Q

Absolute & relative CI for organ donation

A

ABSOLUTE

1) not on ventilator
2) >85
3) primary intra-cerebral lymphoma
4) secondary intra-cerebral tumours
5) Active cancer with spread
6) melanoma
7) TB
8) HIV

RELATIVE

1) systemic sepsis
2) hep b/c
3) trauma to organ

27
Q

What is DIC and why is it a bad sign in shock?

A

When the body goes into shock the inflammatory markers will often also activate the CLOTTING CASCADE leading to SYSTEMIC PLATELET AGGREGATION and widespread microvascular thrombosis

In DIC all of the products for coagulation are used up in the clots in the microvasculature and this means that there are no more platelets etc. for clotting elsewhere - it therefore presents with microvascular bruising or bleeding and extensive bleeding from surgical sites and wounds - microvascular HAEMOLYTIC ANAEMIA

28
Q

4 types of shock & examples

A

1) Hypovolaemic
2) Cardiogenic - MI, arrhythmia
3) Distributive - anaphylaxis, sepsis, neurogenic
4) Obstructive - secondary pump failure due to:
impaired ventricular emptying: PE
impaired ventricular filling: tension pneumothorax

29
Q

8 Signs of hypovolaemic shock

impact on CO & SVR

treatment (1)

A

1) pale, cool, clammy
2) syncope
3) weak
4) confused
5) Tachycardia
6) Tachypnoea
7) Low BP
8) Low urine output
9) signs of cause - tender epigastrium, grey turners/cullens. malaena

Low CO
Low SVR

FLUIDS/blood transfusion

30
Q

10 Signs of cardiogenic shock

Impact on CO & SVR

Treatment (1)

A

1) pale, cool, clammy
2) chest discomfort
3) syncope
4) JVP
5) pulmonary oedema
6) orthopnoea
7) tachycardia
8) tachypnoea
9) low BP
10) low urine output

Low CO
Increased SVR

Inotrope - Dobutamine

31
Q

7 Signs of anaphylactic shock

Impact on CO & SVR

Treatment (4)

A

1) flushed, swollen, itchy
2) low urine output
3) urticaria
4) LOC
5) bronchoconstriction
6) tachycardia
7) low BP

Increase CO
Decrease SVR

500mg adrenaline
fluid challenge
10mg chlorphenamine
200mg hydrocortisone

32
Q

2 definition of septic shock

8 Signs of septic shock

Impact on CO & SVR

Treatment (1)

A

1) sepsis + lactate >2
2) sepsis + needing vasopressor to maintain MAP >65

1) pyrexia and rigors (rarely hypothermia)
2) nausea and vomiting
3) rash and menigism
4) warm peripheries, fast cap refill
5) bounding pulse
6) jaundice
7) bleeding dt coagulopathy (eg from vascular puncture sites)
8) confusion and reduced consciousness

Increase CO
Decrease SVR

Vasopressor - Noradrenaline

33
Q 
sepsis criteria 
temp
HR
BP
RR
WBC
Mental state 
glucose
urine output 
o2 sats 
creatinine 
bilirubin 
platelets
A 
>38.3 or <36
>130bpm
<90
>24
<4 or >12
altered mental state
hyperglycaemia
nil for 18h/<0.5 with catheter 
<91%
creatinine >177
bilirubin >34
platelets <100
34
Q

Signs of obstructive shock

A

1) Muffled heart signs
2) LOC
3) JVP
4) signs of poor perfusion

35
Q

NEWS measures 6 things

A

1) HR
2) BP
3) Temp
4) O2 sats
5) RR
6) ACVPU

36
Q

2 types of intra-vascular monitoring on ICU

A
  • arterial line (measures BP and can get repeat ABGs from)

- central venous catheter (basically invasive measuring of JVP, can also give drugs like noradrenaline through)

37
Q

Define + causes
Type 1 resp failure
Type 2 resp failure

A

Hypoxia (perfusion problem - failure of oxygen exchange)
PaO2 <8
PaCO2 normal/<6

1) cardiogenic pulm oedema
2) pneumonia
3) ARDS
4) asthma
5) lung fibrosis
6) septic shock
7) pneumothorax
8) PE

Hypercarbia - ventilation problem, can’t remove CO2
PaO2 normal/<8
PaCO2 >6

1) COPD
2) chest wall deformities
3) resp muscle weakness eg. gullain barre
4) resp depression from drugs

38
Q

6 Signs of respiratory distress

A

1) cyanosis
2) tripod
3) pursed lip breathing
4) accessory muscles
5) unable to speak complete sentences
6) confusion

39
Q

inspiratory:expiratory ratio

what happens in obstrucive disease

A

1: 2
1: 3, 1:4 etc, trouble expelling air

40
Q

when listening to lungs where must you NOT forget to listen to?

A

AXILLA

41
Q

How to treat:
type 1 resp failure
type 2 resp failure

A

TYPE 1
Nasal cannula 2-6L/min or face mask 5-10L/min

TYPE 2
aim 88-92%
Venturi 24% or 28% or Nasal cannula 1-2L/min

42
Q 
What are the patterns of:
- FEV1
- FVC
- FEV1/FVC ratio
in:
- normal lungs?
- obstructive disease?
- restrictive disease?

incl numbers if poss (% predicted and ratio as a decimal)

A

NORMAL

  • FEV1 >80% predicted
  • FVC >80% predicted
  • FEV1/FVC ratio >0.7

OBSTRUCTIVE - increased airway resistance eg. asthma, COPD

  • FEV1 <80% predicted (reduced)
  • FVC >80% predicted (may be slightly reduced)
  • FEV1/FVC ratio <0.7 (reduced)

RESTRICTIVE - difficulty expanding eg. fibrosis, chest wall disease

  • FEV1 <80% predicted (reduced)
  • FVC <80% predicted (reduced)
  • FEV1/FVC ratio >0.7 (normal)
43
Q

What are the 5 different types of blood products?

what are each used for?

A

WHOLE BLOOD

  • everything, incl clotting factors and plasma EXCEPT platelets
  • rarely used but good for acute large volume bleed

PACKED RED CELLS

  • blood without the plasma
  • treating symptomatic anaemic and major acute blood loss (if give >4 units, give platelets too to ensure stability)

PLATELET CONCENTRATES

  • just platelets
  • used to correct a low platelet count or before a procedure if bleeding is a big risk

FRESH FROZEN PLASMA (FFP)

  • plasma, incl clotting factors
  • used for :
  • – emergency reversal of warfarin
  • – massive haemmorhage
  • – intracranial bleed
  • – DIC (to replace consumed clotting factors)
  • – liver failure with bleeding

CRYPRECIPITATE

  • specific clotting factors are centrifuged out of FFP
  • used to treat specific deficit conditions - haemophilia, vWD, low fibrinogen levels, DIC
44
Q

How much is 1 unit of blood?

A

around 500ml

45
Q

Complications of blood transfusion:

  • immediate? 4
  • delayed? 5
A

IMMEDIATE:

1) Urticaria
2) Febrile non-haemolytic reaction
- Sometimes there is an acute rise in body temperature when the blood is first run through
3) Dilution coagulopathy
- After giving too much packed red cells you can dilute the clotting factors to the point where the person is at a bleeding risk (This is why you give FFP after 4 units of packed red cells)
4) Hyperkalaemia
- Potassium is released during haemolysis and there will be some degree of breaking down of red blood cells in the bag and this will leak into the patient leading to elevated levels of potassium
5) Hypocalcaemia

DELAYED:

1) Delayed haemolytic transfusion reaction
2) Graft versus host disease
3) Immunosuppression
4) Viral infection
5) Iron overload = hemochromatosis

YEAR 4 ACC ME (6 decks)

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