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Critical Care Week 2 Flashcards

1
Q

What is cardiac arrest?

A

Being unable to generate adequate CO to support oxygen demand of tissue

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2
Q

What are the four cardiac arrest rhythms?

A
  • Ventricular fibrillation
  • Pulseless ventricular tachycardia
  • Pulseless electrical activity
  • Asystole
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3
Q

What is the immediate goal of BLS or ACLS?

A

Return of spontaneous circulation

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4
Q

How long should CPR cycles be?

A

2 minutes

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5
Q

What is the only therapy proven to increase survival to discharge in cardiac arrest?

A

Defibrillation of VF and pulseless VT

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6
Q

What are the non-shockable rhythms?

A
  • Asystole
  • Pulseless electrical activity (PEA)
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7
Q

What is the first step in inpatient cardiac arrest?

A

Start CPR (give oxygen, attach defibrillator/monitor)

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8
Q

What should be given for VT/VF after the second shock?

A
  • Epinephrine every 3-5 minutes
  • Consider advanced airway capnography
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9
Q

What should be given for VT/VF after the third shock?

A
  • Amiodarone
  • Lidocaine
  • Treat reversible causes
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10
Q

What is the first step after determining a non-shockable rhythm?

A

Epinephrine ASAP

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11
Q

When can magnesium be used for cardiac arrest?

A

Torsades de pointes

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12
Q

What can the diluent of amiodarone cause?

A

Hypotension, may consider vasopressor

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13
Q

What are the H’s of reversible arrest causes?

A
  • Hypovolemia
  • Hypoxia
  • Hydrogen ion (acidosis)
  • Hyperkalemia
  • Hypothermia
  • Hypoglycemia
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14
Q

What are the T’s of reversible arrest causes?

A
  • Tension pneumothorax
  • Tamponade, cardiac
  • Toxins
  • Thrombosis (pulmonary/coronary)
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15
Q

What can be used to treat hyperkalemia in cardiac arrest?

A
  • Calcium
  • Sodium bicarb + insulin
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16
Q

What is the 4th leading cause of death in the US?

A

Ischemic stroke

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17
Q

What type of stroke accounts for 87% of strokes?

A

Cerebral ischemia

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18
Q

What scoring system do we use to measure stroke risk for prophylaxis decisions?

A

CHA2DS2VASC

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19
Q

What is the most important piece of information when taking a stroke history?

A

Time of symptom onset

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20
Q

What do we use to assess stroke symptoms?

A

NIHSS

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21
Q

T/F: Hemorrhages show up on CT scans much faster than ischemia, making them something to rule out during work-up.

A

TRUE

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22
Q

What treatments are available if a stroke patient presents within 4.5 hours?

A

Fibrinolysis +/- thrombectomy

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23
Q

What are contraindications to fibrinolytics?

A
  • <18 years old
  • Ischemic stroke <3 months
  • Brain/spine surgery <3 months
  • GI bleed <21 days
  • Anticoagulated
  • Endocarditis
  • Current brain hemorrhage
  • Not sure if onset <4.5 h
  • Aortic dissection
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24
Q

What is the alteplase dosing for stroke?

A

0.9 mg/kg, max dose 90 mg
10% bolus over 1 minute
90% infusion over 60 minutes
t1/2 of 5 minutes

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25
What is the tenecteplase dosing for stroke?
0.25 mg/lg, max 25 mg IV push t1/2 20-24 minutes 15x more specific than alteplase
26
What must we bring blood pressure to in order to give fibrinolytics?
160-180 SBP
27
What is our upper allowable limit of blood pressure when NOT giving fibrinolytics?
220/110 (perfuse the injured brain)
28
What are our first line options for blood pressure control for fibrinolysis?
IV labetalol or IV nicardipine (nicardipine if HR <55)
29
Which fibrinolytic is better in large vessel occlusion?
Tenecteplase
30
What are complications of fibrinolytics?
Symptomatic ICH Angioedema
31
What should we do if a patient on fibrinolysis develops symptomatic ICH?
Stop fibrinolytics Cryoprecipitate 10U infused over 10-30 minutes
32
What increases risk of angioedema from fibrinolytics?
ACEi use
33
What should we do if a patient on fibrinolysis develops angioedema?
- Maintain airway - Hold ACEi - Methylprednisolone 80-100mg IV - Diphenhydramine 50mg IV - Ranitidine 50mg IV or famotidine 20mg IV - Epinephrine 0.3mL
34
T/F: Thrombectomy shows evidence for better outcomes with no difference in ICH or mortality risk
TRUE
35
What post-fibrinolytic care must be done?
- Neurologic and BP monitoring for 24h - Dysphagia and aspiration risk - High-dose statin, aspirin for all patients - Dual antiplatelets for low NIH or stent x21 days - DVT prophylaxis >24h post alteplase - Anticoagulation if cardioembolic stroke or Hx of afib
36
When do we consider antiepileptics?
After the 2nd unprovoked seizure
37
What are the first line agents used to STOP seizures?
Benzos: - Lorazepam - Diazepam - Midazolam
38
What are the first line agents used to PREVENT seizures?
Antiepileptics: - Phenytoin - Fosphenytoin - Levetiracetam - Valproic acid
39
What is the pneumonic for phenytoin ADEs?
PHENYTOIN RN P-450 interactions Hirsutism Enlarged gums Nystagmus Yellow-browning of skin Teratogenicity Osteomalacia Interference with folate metabolism Neuropathies (vertigo, ataxia, headache) Rashes/fever, SJS Neutropenia, thrombocytopenia
40
What are the CV effects of phenytoin that are infusion-rate-related?
- Hypotension - Bradycardia - QT prolongation Due to PEG
41
What is the goal level for phenytoin?
10-20 mcg/dL
42
What is the levetiracetam dosage for SE?
60 mg/kg
43
What are ADEs of levetiracetam?
Agitation and drowsiness
44
What drug interacts with phenytoin due to strong protein binding?
VPA
45
How do we treat refractory SE?
1. High-dose benzodiazepines (midazolam bolus + infusion increasing by 2mg/kg) 2. Propofol IV infusion 3. Phenobarbital/pentobarbital coma 4. Ketamine (super refractory)
46
T/F: Intubation is recommended for a pheno/pentobarbital coma
FALSE: intubation is REQUIRED
47
What is our therapy goal for SE?
Attain burst suppression on the LTM
48
What should we do after achieving burst suppression
- Wean off pheno/pentobarbital, propofol, midazolam (earlier)
49
What pain assessment result is used to determine whether opioids are necessary?
CPOT >2 (significant pain)
50
Which opioid is best in renal impairment?
Hydromorphone
51
Which opioid is bad in renal impairment?
Morphine (active metabolite)
52
What does the histamine release cause with morphine?
- Hypotension - Bronchospasm - Urticaria
53
What is the first line continuous drip for pain?
Fentanyl
54
What are issues with fentanyl?
- CYP3A4 interactions (hepatic metabolism) - Tachyphylaxis
55
Which opioid can be used if a patient develops fentanyl tolerance?
Hydromorphone
56
What are non-opioid options for pain relief?
- Acetaminophen - NSAIDs - Methadone (can be weaned off) - Gabapentin - Ketamine - Patient-centered analgesia
57
Which Richmond score do we want to target?
-2 to 0
58
T/F: Propofol can be used to treat pain while sedating
FALSE: no analgesic properties
59
What are ADEs of propofol?
- Respiratory depression (must be intubated for use) - Hypotension - Low CO - Hypertriglyceridemia
60
What are pearls of propofol?
- Can be used for feeding (lipid emulsion) - Quick on and off - Monitor vitals/labs - May be first line for severe alcohol withdrawal, status epilepticus
61
Which sedative has the same MOA as clonidine but 8x stronger?
Dexmedetomidine
62
Dexmedetomidine is FDA approved for how long?
Use <24 hours
63
T/F: Dexmedetomidine can be used as monotherapy for pain AND sedation
TRUE
64
What are the pros of dexmedetomidine?
- No respiratory depression - Opioid-sparing - Adjunct for alcohol withdrawal
65
What are the cons of dexmedetomidine?
- Risk of hypotension - RASS score of -3 or less is unlikely (may be good) - Risk of withdrawal with prolonged use - Drug induced fever
66
What is the shortest onset benzo we use?
Midazolam
67
What are the drawbacks of benzos?
- Increased delirium risk - Increased time on ventilator - Increased length of ICU stay
68
What do we reserve benzos for?
- Status epilepticus - Severe alcohol withdrawal - Severe ARDS requiring deep sedation
69
What are indications of ketamine?
- Anesthesia - Pain - Rapid sequence intubation - Acute severe agitation - Status epilepticus - Treatment resistant depression - PTSD
70
What is the pain dose of ketamine?
0.15-0.5 mg/kg/hr
71
What is the anesthesia dose of ketamine?
0.5-2 mg/kg/hr
72
What is the SE dose of ketamine?
>2 mg/kg/hr
73
What are the advantages of ketamine?
- Favorable hemodynamic - Bronchodilator effects - Opioid sparing
74
What are ADEs of ketamine?
- Emergence reaction (pretreat with benzo/propofol) - Oral secretions - Tachycardia/HTN (may be good)
75
What are modifiable risk factors of dementia?
- Blood transfusions - Benzodiazepines
76
What are non-modifiable risk factors of delirium?
- Increased age - Dementia history - Prior coma - Pre-ICU emergency surgery/trauma - Increase APACHE score
77
What are non-pharm options for delirium?
- Re-orient the patient - Use of hearing aids of glasses - Limit noise and light - Encourage natural sleep-wake cycle - Early mobilization - Family presence - Music therapy - Limit benzos and anticholinergics
78
What are pharmacologic options for delirium?
- Opioids - Dexmedetomidine - Melatonin R-agonists - Antipsychotics (quetiapine, haloperidol, olanzapine)
79
What do we use NMBs for?
- Facilitate mechanical ventilation - Minimize oxygen consumption - Increased muscle activity - Increased intracranial pressures of intra-abdominal pressures - Surgical procedures - Rapid sequence intubation
80
What are disadvantages of NMBs?
- Patient can't communicate - No analgesic or sedative properties - Increase risk of DVT and skin breakdown - Corneal abrasion risk - Critical illness polyneuropathy
81
What is the peripheral nerve stimulator goal when using NMBs?
2 twitches
82
When should we avoid succinylcholine?
- Malignant hyperthermia - Hyperkalemia
83
What is qSOFA criteria for sepsis?
At least 2: - SBP <100 mmHg - RR >22 - Altered mentation
84
What is SIRS criteria for sepsis?
At least 2: - Temp >38 or <36 - HR >90bpm - RR >20 - WBC >12 x 10^9/L or <4 x 10^9/L
85
What should we do in hour 1 of sepsis?
- Start fluids (30 mL/kg crystalloids) - Empiric antibiotics - Vasopressors if hypotensive - Measure lactate - Obtain blood culture before starting antibiotics
86
In what case should we do a workup and administer antimicrobials within 3 hours instead of immediately?
If sepsis is possible and shock is not present
87
What situations indicate MRSA coverage?
- Prior Hx of MRSA infection - Recent IV antibiotics - Presence of invasive devices - Hemodialysis - Recent hospital admissions - Severity of illness
88
What situations should you consider using two gram negative agents for empiric coverage?
- Proven infection with resistant organisms <1 year - Broad spectrum antibiotics <90 days - Travel to highly endemic county <90 days - Local prevalence of antibiotic resistant organisms - Hospital acquired infections
89
How much intravascular volume does 1L of crystalloids yield?
250mL
90
When should we use IV steroids in sepsis?
Poor response to fluids and vasopressors Hydrocortisone IV x3-7 days
91
What is septic shock?
Sepsis + circulatory dysfunction and high mortality

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