Critical Care Modules part II Flashcards
acetylcysteine efficacy in preventing AKI
may help but unclear. it increases Cr clearance by unknown mechanism
tx atrial tach
sotalol, amiodarone, or flecainide. DC cardiovert if unstable
tx pSVT
if stable - vagal, beta block, CCB
unstable - 6 mg adenosine. cardiovert if unsuccessful
tx vtach
stable - IV procainamide, amio, sotalol
unstable - sync cardiovert
pulseless - defib
tx WPW
stable - procainamide +/- amio
unstable - DC cardiovert
drugs to avoid in WPW
anything that inhibits AV node: adenosine, beta blockers, CCB, digoxin
tx polymorphic v tach
immediate defbi. add amio or lidocaine. consier beta blocker
tx torsades
stable - mag
unstable defib or transvenous pacing
tx irregular SVT w/ BBB (only one of its kind)
DC cardioversion
drugs to avoid in irregular SVT w/ BBB (only one of its kind)
CCB, beta blockers, adenosine, digoxin –> sudden death
tx sinus brady
if sx - atropine, dopamine or epi
tx sinus brady 2/2 drug toxicity
for CCB or beta blocker tox - calcium and glucagon
for dig tox or hyper k - digoxin antibody fragments
tx ventricular escape rhythm
use pacing. usually unstable
AVOID lidocaine –> asystole
what has higher water content, muscle or fat
muscle
infants have proportaionally (?more/less?) body water
more
volume loss for classes of hemorrhage shock
I < 750
II 750-1500
III 1500-3000
IV > 3000
where does buffering in LR come in
liver converts lactate to bicarb. thats why in liver transplant patients we avoid LR.. hard to tell real lactate elevation from impaired clearanc
transexamic acid MOA
blocks fibrinolysis to promote clotting
dosing of transexamic acid
given as loading dose w/in 8 hrs, and as driop over 8 hrs
clinical effect of transexamic acid
decreases mortality but doesn’t change transfusion requirement
how many liters can you transfuse in 1 hr for 16 G? 18 G?
13 L/hr w/ 16G
6 L/hr w/ 18G
glucose goals
<180 for most patients. <150 for cardiac.
keep >100 in neuro pts. >70 in most others
tx hypoglycemia
stop insulin
10-20 g D50w
repeat glucose check and dextrose q15 min until >70
Kussmaul respiration
deep slow hyperventilation of DKA
focal neuro deficits are seen in (?DKA/HHNC?)
hyperosmolar hyperglycemic nonketotic coma
weaning off SIMV
decrease number of machine given breaths
weaning off AC
increase time on trach collar, then let them rest with AC
weaning off PS
decrease pressure over time
what lyte disorder is an under dx cause of inability to wean off vent
hypo phos - causes weakness
indications for ICP monitoring
Salvageable pt w/ severe TBI (GCS 3-8) AND... abnormal CT scan OR normal CT scan but w/ 2 or 3 of these - age > 40 - motor posturing - SBP < 90
sedatives to use to prevent elevated ICP
benzos, prophofol, opiates. in refractory cases, paralytics, barbiturates.
medical tx elevated ICP
sedation, hypertonic saline or mannitol, optimize MAP, therapeutic hypothermia.
for refractory cases, barbirturate coma, paralytic, hyperventilation
scales for SAH prognosis
Hunt and Hess scale.
World Federation of Neurologic surgeons scale.
triple H therapy for SAH
hypervolemia, hypertension, hemodilution - prevents delayed cerebral ischemia
midaz AE
accumulates in kidney dysfunction –> prolonged sedation
propofol-related infusion syndrome
acidosis, arrhythmia, ARF, shock
pentobarbital AE
hypotension, myocardial depression, immunocompromise
only acute stroke tx that improves mortality
decompressive craniectomy after malignant large vessel territory infraction w/ cerebral edema
immunonutrition
use in burn or trauma patients. glutamine, arginine, antioxidants, omega-3 fatty acids
lyte distrubance in refeeding syndrome
low phos, mag, k
early TPN shows benefit only in these cases
1) malnourished patients who will have major upper GI surgery in 5-7 days
2) ICU patients malnourished on admission
indications for stress ulcer GI ppx
resp failure, TBI, coag disorder, burn/major trauma, hypotension, hx GIB, transplant
AE PPI
N/V/D, rebound acid hypersecretion, osteoporosis, c diff
AE H2 blockers
HA, constipation, diarrhea
AE sucralfphate
low k, low phs, aluminum tox
RASS score range
-5 to +4
RASS -5
unarousable
RASS -4
any movement to physical stim
RASS -3
any movement to voice
RASS -2
wakes for less than 10 secs
RASS +2
Frequent nonpurposeful movement or patient–ventilator dyssynchrony
RASS +3
Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff
RASS +4
overly combative/violent
pain med to avoid in kidney injury
morphone. metabolites are toxic and accumulate
pain med that causes qt prolongation
methadone
dosing equivalents for fent, dilaudid, morphine
100 ug fentanyl = 1.5 mg dilaudid = 10 mg morphine
AE propofol
propofol infusion syndrome - asystole/brady, rhabdo, severe metabolic acidosis.
note that prop has no analgesia
AE for atypicla antipsych
qt prolongation and hypotension. no strong evidence they even work well for delirium but we use anyway
AE etomidate
adrenal insufficiency
SIRS criteria
temp >38/<36
HR >90
RR >20 or PCO2<32
WBC <4/>12 or >10% bands
SvO2 in septic patients
under-resuscitated have low SvO2. resuscitated patients have high SvO2 (textbook answer at least)
lactate and mortality in septic shock
if >4 and does not correct w/in 6 hrs of resuscitation, increases mortality
initial fluid challenge sepsis
30 mL/kg
goal directed therapy
- fix CVP 8-12 w/ fluids
- fix MAP >65 w/ pressors if needed
- fix ScVO2 >65% with RBCs if needed
how is procalcitonin used in empiric therapy
low procal can be use to stop abx if no infection identified. should be high w/ bacterial infection
pressors in septic schock
1st line nore. 2nd vasopressin in addition (lowers nore requirements).
epi can be added or replace nore.
AVOID dopamine (more AEs, icnreases mortality)
when to use steroids in shock
vasopressin resistant shock
surviving sepsis bundle w/in 3 hrs
blood cx, abx, measure lactate, 30cc/kg bolus
surviving sepsis bundle w/in 6 hrs
pressors if MAP <65
if in septic shock or lactate >4 despite resus, measure CVP and ScVO2
remeasure lactate if first was elevated
ASIA scale A
complete neuro loss in spinal cord injury
ASIA scale E
normal
ASIA scale B
sensory intact, but no motor
ASIA scale C
sensory intact, motor barely preserved
ASIA scale D
sensory intact, motor preserved more than C
type of SCI caused by extension injury es/ in pre-existing stenosis
central cord syndrome
s/s central cord syndrome
greater impairement of upper extremities. distal more than proximal. urinary retntion. sparing of sacral sensation
SCI caused by flexion injury w/ vasc compromise
anterior cord syndrome. also caused by ASA occlusion
s/s anterior cord syndrome
loss of pain and temp and motor. maintained vibrationa nd position
in brown-sequard loss of proprioception is (ipsi/contra?)
ipsilateral loss below lesion
in brown sequard loss of pain/temp is (ipsi/contra)
contra below lesion
may be ipsi @ level
conus medullaris vs. cauda equina
equina is LMN. CMS more likely bilateral
pathogenesis of autonomic dysrefelxia
SCI above T5 prevents descending inhibition from brainstem centers, so adrenal glands presumably release catecholamines
s/s autonomic dysreflexia
HTN and profuse sweating in resposne to distended viscus
SCI where can cause paradoxical movement on inspiration
between C4 and T6. paralyzes intercostal contraction
SCI where can cause bronchospasm and why
between C4 and T6, loss of sympathetic innervation
DVT algorithm, low pretest
proximal compression u/s is enough to rule out. d-dimer can also help r/o if really low suspicion
DVT algorithm, high pretest
whole leg u/s can rule out immediately. proximal can r/o if repeated in 1 week
PE algorithm, low pretest
can wait to start a/c if you want
get spiral CT or V/Q. negative CT, or low or nl V/Q is enough to r/o. if inadequate, do DVT u/s
PE algorithm, high pretest
start anticoagulation
get spiral CT or V/Q. if negative, still get DVT u/s. if those negative, can even consider conventional angio
DVT algorithm, mod pretest
same as high pretest algorithm: whole leg u/s can rule out immediately. proximal can r/o if repeated in 1 week
PE algorithm, intermediate pretest
hybrid of low and high
definitely start anticoagulation (like high) but can rule out with negative CT
DVT ppx nonsurgical
LMWH or heparin preferred. if high bleeding risk, then mechanical can be a substitute
DVT surgical
mod risk is LMWH or heparin or mechanical
high risk both chemical and mechanical
if cancer, definitely LMWH
if high bleeding risk, only mechanical
ECG PE
S1 q3 t3
contraindications LMWH
renal failure or expected need for thrombolysis
