Final deck Flashcards
AFIB vs A flutter pathophysiology
In atrial fibrillation, the atria beat irregularly. In atrial flutter, the atria beat regularly, but faster than usual and more often than the ventricles. (re-entrant circuirt around the tricuspid valve.)
T/F supraventericular arrythmias have a regular QRS complex
T
T/F Ventricular arrythmias (which are a type of tachyarrythmia) have wide QRS
T
Types of bradyarrythmias due to the atria
Respiratory sinus: RR shortens during inspiration, lenghtens during expiration
Sinus bradycardia: physiological, sick sinus sx, BB, CCB
Sinus pause/arrest: CVD. Absent P wave + escape rhythm
Tachycardia/bradycardia sx: Abnormal supraventricular impulse generation and conduction
Types of bradyarrythmias due to the AV node
AV block
Types of supraventricular arrythmias of atrial origin
Premature beats: electrolyte imbalance (abnormal/absent P waves)
Sinus tachycardia (max rate is 180, narrow QRS)
Atrial flutter: re-entrant rhythms within the atria
A fib: mechanism unknown
Atrial tachycardia: wither focal atrial tachycardia (regular) or multifocal atrial tachycardia (irregular)
Types of supraventricular arrythmias of AV node entry
AVRT: due to an accessory pathway. Abrupt onset. Regular.
AVNRT
Junctional tachycardia (AV node takes over the pacemaker function. can occur in Digitalis toxicity, MI, myocarditis)
Ventricular arrythmias
Premature ventricular beats (hypoxia, hyperthyroidism, electrolyte abnormalities)
V Tach (CAD, MI)
Torsades de pointes (long QT, hypokalemia)
V-fib: MI
Cinchonism:
headache, hearing/vision loss, tinnitus, psychosis and cognitive impairment, associated with quinidine use
Most common causes of extrinsic SA node dysfunction
Drugs, ANS influence.
Hypothyroidism, hypothermia, hypoxia, bezolf-jarish reflex, ICP (Cushings response), hyperkalemia/magnesemia
Bezold Jarish reflex
increased vagal tone due to ischemia
TX of arrythmia
1- TX underlying cause
2- If can’t treat cause:
What factors contribute to the severity of a burn
Depth and surface area involved
How do you decide if the pt is on the right amount of fluids
Based on the urine output and clincial stability
Labs needed for DX/MX of burns
Pulse oximetry, ABG, electrolyte and creatinine levels
Most common cause of death after burns are
shock, sepsis, respiratory failure
Common pathogens that infect burns
mrsa, pseudomonas, klebsiella, acinetobacter, candida
Lun-Browder charts to evaluate the surface area of burn involved, the palm rule, wallace’s rule of nines
Lun-Browder: age specific
Palm rule: palm is 1% of body area
Wllace’s rule of nines: for adults
Clinical features of burn patient
Shock (hypotension, anuria) ARDS
Compartement syndrome (if in abd then JVD, tachycarida, hypotension)
Acute limb ischemia
What triggers a change in respiration?
PaCO2 levels
Normal Pa02 calculation
109 - 0.4 (age of pt)
ARDS has what
bilateral involvemetn and diffuse distribution
Calculate the anion gap (must be corrected for albumin - as there is an increase
the anion gap by 2.5 mEq/L for every 1 g/dL reduction in serum albumin.)
[Na] - [Cl + HCO3]
[137] - [104 + 24] mEq/L
10 +/- 2 is normal
If its elevated you are in metabolic acidosis
If low anion gap: wasting issues (diarrhea, renal tubular acidosis) (hypoalbuminemia, hyperkalemia)
If high anion gap: sepsis or liver dx, intoxication, drugs
Effects of acidosis
Lungs: hyperventiation (kussmall), shift of ocyHb surve to right (bohr effect)
CV: tachycardia, peripheral vasodilation
increased bone resorption, hyperkalemia, reduced lactate clearance
Where does a CVC go?
Enters through subcalvian vein, or interior jugular vein. lies at border with right atrium
What three values influence oxygen delivery to tissues
Hb concentration
O2 bound to Hb
Pumping of blood by the heart to the tissues
O2 delivery (ml/min) = 1.34 (ml/g) x SaO2 (fraction) x Hb (g/dL) x CO (dL/min)
Possible methods to increase O2 delivery
blood transfusion
O2
crystalloids
How todecrease the pts consumption of O2
correct fever
no exercise
treat increased breathing effort (ventilator)
sedate
Cardiac arrest manifests as
Apnea, pulselessness, loss of consciousness
Most common cuases of cardiac arrest in adults v children
Adults : CAD, hypothermia
Kids: hypoxia (airway obstruction)
Reversible causes of cardiac arrest (H’s and T’s)
Hs: hypoxia, hypovolemia, hydrogen ions (acidosis), hypo/hyperkalemia, hypothermia
- Ts: toxins, thrombosis (coronary and pulmonary), tamponade, tension pneumothorax
ALSO: hypoglycemia, hypocalcemia, hypomagnesemia, anaphylaxis, asthma
compression rate
100-120 per minute
5-6 cm deep
allow full chest recoil between compression
restart CPR immediately after shock delivery
30 compression 2 breaths
PEA can be due to
cardiac tamponade
pulmonary embolism
tension pneumothorax
hypovolemic shock
Causes of asystole
hypoxia
hyperkalemia
Define shock
a life-threatening, generalized form of acute
circulatory failure associated with inadequate oxygen utilization by the cells
circulation evaluation
Several clinical parameters must be integrated to obtain information about patient’
circulation, including heart rate (60-90bpm), blood pressure (90-120mmHg), capillary
refill time/CRT, color and temperature of the skin, urine output and edema.
fluid challenge
It consists in administering small
boluses of fluids (4ml per kg/ 250 mL of crystalloids) over 15 minutes, while vital parameters are checked.
A positive fluid challenge test is defined as an increase in cardiac output in response to the increased blood volume (increased pre-load).
When is the only time you use colloidal solutions
Rarely in severely low oncotic pressure
When is the only time you use colloidal solutions
Rarely in severely low oncotic pressure.
They increase Intravascular volume wayyy more than crystalloids do
what are the three types of fluids
crystalloids (minerals, dextrose)
colloids (albumin, starch)
balances IV fluid solutions (the aboce which dont alter homestasis of ECC)
Osmolarity vs osmolarity vs tonicity
Osmolality: the concentration of dissolved particles per unit mass of solution (mOsm/kg); preferred term to describe the osmotic pressure of biological systems
Osmolarity: the concentration of solutes per unit volume of solvent (mOsm/L); often used interchangeably with osmolality in clinical practice Preferred term to describe the osmotic pressure of parenteral fluids
Tonicity: the capacity of an ECF to create an osmotic gradient that will cause water to move into or out of the ICC; cannot be measured and has no unit (dep on Na, K)
The best solution for IV fluid resus is
isotonic crystalloids (are normal saline or ringers lactate)
T/F IO (intraosseous) access is preferred to CV access for resus
T
But the best is peripheral IV
Why perform fluid challenge?
to differentiate between hypovolemia and euvolemia
Define critical illness
A critical illness is any disease process which causes physiological instability leading to disability
or death within minutes or hours. Generally, the perturbation of the neurological and
cardiorespiratory systems has the most immediate life-threatening effects.
Five parameters for critical illness dx then 5 others after
Level of consciousness
RR
HR
BP
urine output
Others: age, comorbidities, current drug regime, magnitude of change from baseline
What issues are present with breathing
asthma
pulmonary edema
tension pneumothorax
hemothorax
OPACS for B (breathing) assessment
Observation of the thorax during the respiratory process (moving symmetrically or asymmetrically, e.g due to an obstruction in one bronchus)
Palpation (assess if there is a subcutaneous emphysema)
Auscultation: crackles can be heard in case of congestion of the alveoli by fluid as in case of pulmonary edema or pneumonia, while wheezing can appear in case of an asthmatic crises. The obtusity at the bases of the lungs can signal a pleural effusion or a
pneumothorax.
* Count (respiratory rate): measure it accurately because it is a very important sign in case of critically ill patient.
* Saturimetry (normally >96%, in COPD patients the target should be 88-92%).
What is the Early warning score?
Takes into consideration the vital parameters and all the deviations from the normality give us a score. The higher is the score the more the patient is critical. This is a very useful tool for the
communication among health care professionals.
Includes: HR, SPO2, TEMP, SBP, RR, STATE OF CONSCIOUSNESS, O2
0-4: low risk, 7+ high risk
What are the three peaks of dying risk after trauma
1: Immediately after (aortic laceration, CNS)
2: 3-4 hours (due to hemorrhages)
3: due to sepsis and multiple organ failure
What are the new resuscitatino targets?
damage control surgery
permissive hypotension (keep SBP at 80mmHG until major bleed has been stopped)
hemostatis resuscitation (restore normal tissue perfusion, preserving clotting)
three most important factors causing TIC
acidosis
hypothermia
blood dilution
T/F fibrinogen is the first coagulation factor that reaches critically low values in TIC.
T
Steps of hemostatis resuscitation
correct hypothermia
correct acidosis
correct hypocalcemia (to >1mmol/L)
blood componenets
tx of coagulopathy
what is PCC (a factor concentrate)
It is a powder for dissolution containing pro- and anti-coagulant factors (II – VI – IX – X – PC – PS)
and heparin. It is sold in vials of 500 IU or 1000 IU vials. It can be stored at room temperature and
quickly dissolved in sterile water. It is the first choice for warfarin reversal.
massive transfusion prediction scores
ABC score: it doesn’t require any lab exam, very easy to use, can be used with pre-hospital
information. Takes 4 things: presence of penetrating trauma, positive FAST sca, SBP<90, HR>120
Score of <2: unlikely need for massive transfusion.
Score of >2: massive transfusion program will likely be necessary.
* TASH score: requires lab tests (Hb);
1, SBP; 2, Hb; 3, intra-abdominal fluid; 4, complex long bone and/or pelvic fractures; 5, HR; 6, base excess; and 7, gender.
Score of >24: positive, massive transfusion program will likely be necessary
Goals of damage control surgery
rapidly control bleeding
containing abdominal contamination
restrogin patient physiology
achieving temporary abdo wall closure
When to perfrom emergency thoracotomy
In case of thoracic penetrating trauma with PEA
AMS can manifest as
hyperalertness
Somnolence
lethargy
obtundation
stupor
Four mechanisms of hypoxia
hypoventilazione
Bradypnea (<12)
V/Q mismatch (COPD, emphysema, p. embolism)
Shunt (pneumonia, atelectasia, lung tumor, CHF, ARDS)
Diffusion abnormality
Define shock
circulatory disorder leads to inadequate organ perfusion, tissue hypoxia and microcirculation disturbance that eventually results in irreversable organ damage
What 3 things can help distinguish between the types of shock
Pulmonary capillary wedge pressure
CO
Systemic vascular resistance
what is the shock index?
HR/SBP
Parameters of hypovolemic shock and tx options
low CVP
LOW Pulmonary capillary wedge pressure
LOW CO
HIGH SVR
HIGH HR
TX: fluid resus, blood transfusion, hemostatic control
Parameters of cardiogenic shock, causes and tx options
cardiac ischemia, arrythmias, valvulopathy, toxic substances
HIGH CVP, HIGH PCWP, LOW CO, HIGH SVR, DISTEDED JVP
TX: IV fluids if fluid responsive, inotropic support, vasopressors, diuretics
Parameters of obstructive shock, causes and tx options
cardiac tamponade (causes impaired filling of right ventricle), tension pneumothorax (obstructs venous return), massive PE (increases ventricular afterload)
HIGH CVP, LOW CO, HIGH SVR, HIGH HR
TX: fluid resus, relieve obstructions
Types of disdributive shock
septic
neurogenic
anaphylactic
Parameters of septic shock and tx options
flushed skin!!
TX: fluid resus, vasopressors, antibiotics, infections source control (abscess, drainage, surgery)
Parameters of anaphylactic shock and tx options
epinephrine
fluid resus
Parameters of neurogenic shock and tx options
due to CNS injury
Has bradycardia unlike other shocks
TX: fluid resus, vasopressors, atropine if severely bradycardic
How many phases does shock have
3
Routine investigations for shock
high lactate
ABG
renal function, liver function, coagulation panel if in sispected stage 3
Base deficit in shock pts
if BD> or equal to 10 pt has severe hemorrhagic shock
Septic shock management
1 hour bundle:
crystalloids 30ml/kg/hr
antibiotics
vasopressors (start with norepi, if doesnt work add vasopressin)
Anaphylactic shock management
epinepphrin IM 1:1000
fluids
add anti histamines and corticosteroids only after initial tx
tx for refractory shock
corticosteroids (hydrocortisone)
bicarbonate
mechanical circulatory support (ECMO for ARDS)
ACS includes
STEMI
NSTEMI
Unstable angina (myocardial ischemia at rest or minimal exertion in absence of cardiomyocyte necrosis)
Most common sources of sepsis infection
pneumonia
abdominal infections
UTI
SOFA score (range from 0-24, 0 is normal)
The SOFA score assesses the proper functioning or the failure of 6 organs through the results of in-hospital readily available tests:
- Lungs (respiration) → PaO2/FiO2 and need for support (oxygenation)
- Platelets (coagulation) → platelet count
- Liver → total bilirubin concentration
- Cardiovascular system (circulation) → ABP (MAP) and need for support (drugs)
- Brain → Glasgow Coma Scale
- Kidney → creatinine concentration
qSOFA score
considers 3 variables that reflect the function of 3 organs only:
- Lungs (respiration) → respiratory rate ≥ 22
- Cardiovascular system (circulation) → systolic blood pressure ≤ 100 mmHg
- Brain → mental status: altered cognition (if GCS < 15 or if AVPU is not A)
If ≥ 2 of these signs are present, the patient should be considered at risk of having an organ dysfunction/sepsis and thus referred to the hospital
what three things determine if an antibiotic is correct
timing
penetration into infected tissue
pharmacodynamic/pharmacokinetic properties
septic shock antibiotics should be given
w/in the first hour
dont use linezolid for MRSA in septic shock bc?
it is bacteriostatic
screen for MDR pathogens
rectal swab for carbapenen reisitant K pneumonia
Nasal swab for MRSA
cutaneous swab for MDR Acinetobacter baumanii
A person is at risk of ESBL-producing microorganism infection if at least one among the following risk factors is present:
Previous therapy with a quinolone or a cephalosporin in the last 3 months
▪ 4 cycles of antibiotic therapy in the last year (especially cephalosporins and quinolones)
▪ Previous isolation of ESBL producing organisms
Stay in long term care facilities (LTCF)
Define a hypertensive crisis
acute increases in blood pressure (generally defined as ≥ 180/120 mm Hg) that cause or increase the risk of end-organ damage, i.e., damage to the brain (e.g., encephalopathy, stroke), eyes (e.g., retinopathy), cardiovascular system (e.g., ACS, pulmonary edema, aortic dissection), and/or kidneys (e.g., acute kidney injury).
define malignant hypertension
severe hypertension with retinopathy (flame hemorrhages, papilledema)
which drugs exacerbate hypertenison
MAOi (consuming wine/choc/cheese/cured meat)
TCA
NSAIDS
cocaine
amphetamines
ecstasy
stimuant diet pills
Hypertensive emergency management
first hour: reduce BP by 25%
For non specific sx: rapid acting oral antiHTN (clonidine, labetalol, prazosin)
Aortic dissection: esmolol 500-1000mcg/Kg IV bolus in 1 min then 50mcg IV infusion (follow with vasodilators nitroprusside 0.3-0.5 mcg/kg)
P. edema: nitroglycerin 5 mcg/min infusion
ACS: nitroglycerin, esmolol
AKI: nicardipine 5mg/hour
catecholamine excess: benzo 5mg IV bolus
if GCS <8 then pt is in a coma so
need to be put ona ventilator
The most commonly involved nerve in TBI is
the facial nerve, 7th
