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703 > Critical Care Week 2 > Flashcards

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
Q

What is the tenecteplase dosing for stroke?

A

0.25 mg/lg, max 25 mg
IV push
t1/2 20-24 minutes
15x more specific than alteplase

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26
Q

What must we bring blood pressure to in order to give fibrinolytics?

A

160-180 SBP

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27
Q

What is our upper allowable limit of blood pressure when NOT giving fibrinolytics?

A

220/110 (perfuse the injured brain)

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28
Q

What are our first line options for blood pressure control for fibrinolysis?

A

IV labetalol or IV nicardipine
(nicardipine if HR <55)

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29
Q

Which fibrinolytic is better in large vessel occlusion?

A

Tenecteplase

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30
Q

What are complications of fibrinolytics?

A

Symptomatic ICH
Angioedema

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31
Q

What should we do if a patient on fibrinolysis develops symptomatic ICH?

A

Stop fibrinolytics
Cryoprecipitate 10U infused over 10-30 minutes

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32
Q

What increases risk of angioedema from fibrinolytics?

A

ACEi use

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33
Q

What should we do if a patient on fibrinolysis develops angioedema?

A
  • Maintain airway
  • Hold ACEi
  • Methylprednisolone 80-100mg IV
  • Diphenhydramine 50mg IV
  • Ranitidine 50mg IV or famotidine 20mg IV
  • Epinephrine 0.3mL
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34
Q

T/F: Thrombectomy shows evidence for better outcomes with no difference in ICH or mortality risk

A

TRUE

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35
Q

What post-fibrinolytic care must be done?

A
  • 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
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36
Q

When do we consider antiepileptics?

A

After the 2nd unprovoked seizure

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37
Q

What are the first line agents used to STOP seizures?

A

Benzos:
- Lorazepam
- Diazepam
- Midazolam

38
Q

What are the first line agents used to PREVENT seizures?

A

Antiepileptics:
- Phenytoin
- Fosphenytoin
- Levetiracetam
- Valproic acid

39
Q

What is the pneumonic for phenytoin ADEs?

A

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
Q

What are the CV effects of phenytoin that are infusion-rate-related?

A
  • Hypotension
  • Bradycardia
  • QT prolongation

Due to PEG

41
Q

What is the goal level for phenytoin?

A

10-20 mcg/dL

42
Q

What is the levetiracetam dosage for SE?

A

60 mg/kg

43
Q

What are ADEs of levetiracetam?

A

Agitation and drowsiness

44
Q

What drug interacts with phenytoin due to strong protein binding?

A

VPA

45
Q

How do we treat refractory SE?

A
  1. High-dose benzodiazepines (midazolam bolus + infusion increasing by 2mg/kg)
  2. Propofol IV infusion
  3. Phenobarbital/pentobarbital coma
  4. Ketamine (super refractory)
46
Q

T/F: Intubation is recommended for a pheno/pentobarbital coma

A

FALSE: intubation is REQUIRED

47
Q

What is our therapy goal for SE?

A

Attain burst suppression on the LTM

48
Q

What should we do after achieving burst suppression

A
  • Wean off pheno/pentobarbital, propofol, midazolam (earlier)
49
Q

What pain assessment result is used to determine whether opioids are necessary?

A

CPOT >2 (significant pain)

50
Q

Which opioid is best in renal impairment?

A

Hydromorphone

51
Q

Which opioid is bad in renal impairment?

A

Morphine (active metabolite)

52
Q

What does the histamine release cause with morphine?

A
  • Hypotension
  • Bronchospasm
  • Urticaria
53
Q

What is the first line continuous drip for pain?

A

Fentanyl

54
Q

What are issues with fentanyl?

A
  • CYP3A4 interactions (hepatic metabolism)
  • Tachyphylaxis
55
Q

Which opioid can be used if a patient develops fentanyl tolerance?

A

Hydromorphone

56
Q

What are non-opioid options for pain relief?

A
  • Acetaminophen
  • NSAIDs
  • Methadone (can be weaned off)
  • Gabapentin
  • Ketamine
  • Patient-centered analgesia
57
Q

Which Richmond score do we want to target?

A

-2 to 0

58
Q

T/F: Propofol can be used to treat pain while sedating

A

FALSE: no analgesic properties

59
Q

What are ADEs of propofol?

A
  • Respiratory depression (must be intubated for use)
  • Hypotension
  • Low CO
  • Hypertriglyceridemia
60
Q

What are pearls of propofol?

A
  • 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
Q

Which sedative has the same MOA as clonidine but 8x stronger?

A

Dexmedetomidine

62
Q

Dexmedetomidine is FDA approved for how long?

A

Use <24 hours

63
Q

T/F: Dexmedetomidine can be used as monotherapy for pain AND sedation

A

TRUE

64
Q

What are the pros of dexmedetomidine?

A
  • No respiratory depression
  • Opioid-sparing
  • Adjunct for alcohol withdrawal
65
Q

What are the cons of dexmedetomidine?

A
  • Risk of hypotension
  • RASS score of -3 or less is unlikely (may be good)
  • Risk of withdrawal with prolonged use
  • Drug induced fever
66
Q

What is the shortest onset benzo we use?

A

Midazolam

67
Q

What are the drawbacks of benzos?

A
  • Increased delirium risk
  • Increased time on ventilator
  • Increased length of ICU stay
68
Q

What do we reserve benzos for?

A
  • Status epilepticus
  • Severe alcohol withdrawal
  • Severe ARDS requiring deep sedation
69
Q

What are indications of ketamine?

A
  • Anesthesia
  • Pain
  • Rapid sequence intubation
  • Acute severe agitation
  • Status epilepticus
  • Treatment resistant depression
  • PTSD
70
Q

What is the pain dose of ketamine?

A

0.15-0.5 mg/kg/hr

71
Q

What is the anesthesia dose of ketamine?

A

0.5-2 mg/kg/hr

72
Q

What is the SE dose of ketamine?

A

> 2 mg/kg/hr

73
Q

What are the advantages of ketamine?

A
  • Favorable hemodynamic
  • Bronchodilator effects
  • Opioid sparing
74
Q

What are ADEs of ketamine?

A
  • Emergence reaction (pretreat with benzo/propofol)
  • Oral secretions
  • Tachycardia/HTN (may be good)
75
Q

What are modifiable risk factors of dementia?

A
  • Blood transfusions
  • Benzodiazepines
76
Q

What are non-modifiable risk factors of delirium?

A
  • Increased age
  • Dementia history
  • Prior coma
  • Pre-ICU emergency surgery/trauma
  • Increase APACHE score
77
Q

What are non-pharm options for delirium?

A
  • 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
Q

What are pharmacologic options for delirium?

A
  • Opioids
  • Dexmedetomidine
  • Melatonin R-agonists
  • Antipsychotics (quetiapine, haloperidol, olanzapine)
79
Q

What do we use NMBs for?

A
  • Facilitate mechanical ventilation
  • Minimize oxygen consumption
  • Increased muscle activity
  • Increased intracranial pressures of intra-abdominal pressures
  • Surgical procedures
  • Rapid sequence intubation
80
Q

What are disadvantages of NMBs?

A
  • Patient can’t communicate
  • No analgesic or sedative properties
  • Increase risk of DVT and skin breakdown
  • Corneal abrasion risk
  • Critical illness polyneuropathy
81
Q

What is the peripheral nerve stimulator goal when using NMBs?

A

2 twitches

82
Q

When should we avoid succinylcholine?

A
  • Malignant hyperthermia
  • Hyperkalemia
83
Q

What is qSOFA criteria for sepsis?

A

At least 2:
- SBP <100 mmHg
- RR >22
- Altered mentation

84
Q

What is SIRS criteria for sepsis?

A

At least 2:
- Temp >38 or <36
- HR >90bpm
- RR >20
- WBC >12 x 10^9/L or <4 x 10^9/L

85
Q

What should we do in hour 1 of sepsis?

A
  • Start fluids (30 mL/kg crystalloids)
  • Empiric antibiotics
  • Vasopressors if hypotensive
  • Measure lactate
  • Obtain blood culture before starting antibiotics
86
Q

In what case should we do a workup and administer antimicrobials within 3 hours instead of immediately?

A

If sepsis is possible and shock is not present

87
Q

What situations indicate MRSA coverage?

A
  • Prior Hx of MRSA infection
  • Recent IV antibiotics
  • Presence of invasive devices
  • Hemodialysis
  • Recent hospital admissions
  • Severity of illness
88
Q

What situations should you consider using two gram negative agents for empiric coverage?

A
  • 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
Q

How much intravascular volume does 1L of crystalloids yield?

A

250mL

90
Q

When should we use IV steroids in sepsis?

A

Poor response to fluids and vasopressors
Hydrocortisone IV x3-7 days

91
Q

What is septic shock?

A

Sepsis + circulatory dysfunction and high mortality

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