General ICU stuff Flashcards

1
Q

Protective effects of hypothermia

A
  • reduced CMR
  • Reduced cerebral O2 demand
  • decreased production of neurotraminssters
  • reduced free radical exposure and oxidative stress from reperfusion
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2
Q

Therapeutic hypothermia

A

Cooling patient to subnormal temperature for specific indication
previously used in OOHCA, TBI
now neonatal hypoxic brain injury and deep hypothermic circulatory arrest in aortic surgery

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3
Q

Targeted temperature management

A

constant targeted temperature maintained
unconscious cardiac arrest patient
- OHCA initial shockable rhythm (previous recommendation)
- OHCA initial non-shockable (previous suggestion)
CI to < 33 C include severe systemic infection and coagulopathy

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3
Q

TTM fallen out of favour

A

now avoidance of hyperthermia and maintenance of low normal temperature
TTM trial 33 vs 36 degrees OOHCA no difference in mortality or disability
TTM 48 33 degrees for 24 or 48 hours. no difference, sig more adverse events
TTM 2 33 vs 37.5 no difference

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3
Q

TTM methods

A

devices - feedback loop with monitoring and delivery - heat exchange water circulating cooling pads in arctic sun
simple ice packs
intravascular head exchanger
sedation with NMB due to shivering
rewarming risks of rebound hyperthermia, vasodilatory hypotension, reperfusion injury

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3
Q

How would you manage temperature following cardiac arrest

A
  • temperature control
  • actively preventing fever > 37.7
  • use cooling device to target temperature of 37.5 if antipyretics, exposure etc unscuccesful
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3
Q

How would you manage temperature following TBI

A

Normothermia aiming 36-37

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3
Q

challenges of nutritional assessment in ICU

A

patient
- extremes of prior health
- frailty
- varied population
illness
- acute gut injury
- sepsis
- major trauma
- organ failure
treatment
- ventilation
- RRT
- sedation

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3
Q

MUST score

A
  • BMI
  • % change
  • acute disease effects
    add scores for overall risk
    0 = low 2 or more = high
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3
Q

nutritional assessment on icu

A

ESPEN
- all patients > 48hr on icu risk of malnutrition
- pre icu weight loss, pre icu decline in physical performance
- muscle mass, body composition, strength

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3
Q

BMR

A

energy expended per unit time during rest.
40cal/m2/hr
energy expenditure is sum of internal heat produced and external work. internal heat = BMR + thermic effectst of food
critical illness - catabolic and significant energy deficit
measuring energy expenditure
- indirect calorimetry - need VO2 / VCO2
- feeding equations - Harris - Benedict, Schofield based on gender, age, sizue

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4
Q

respiratory quotient

A

CO2 : O2 during respiration
carb = 1.0 protein 0.8 lipid 0.7

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5
Q

body weight terms

A

actual / total = measured weight
LBW - excludes fat
IBW - based on height
ABW - use in obese patients

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6
Q

Daily nutritional requirements in critical illness

A

energy - 25-35kcal/kg
carb - 2g/kg
protein 0.8-1.5g/kg
lipid 1-1.5g/kg
water 30ml/kg
Na K Cl 1mmol/kg
PO4 0.4mmol/kg
Mg and Ca 0.1mmol/kg

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7
Q

Nutritional support

A

oral supplements, EN, PN
- increased risk of malnutrition
- little or no diet for 5 days, continuing another 5 days
- poor absorption
- high nutritional loss
- high demand

ESPEN - EN via NG within 48hrs once stable
50% of estimated target, increase to 70% after 48hrs

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8
Q

contraindications to EN

A
  • gut - anastatmotic leak, necrosis, ischaemia
  • maintaining oral inake
  • peritonitis
  • uncontrolled severe shock
    relative
  • > 500ml gastric aspirate/6 hrs
  • abode compartment syndrome
  • < 5 days fasting
  • localised peritonitis, abscess

EN disadvantages
- needs healthy gut
- tube discomfort
- tube misplacement
- diarrhoea

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9
Q

trophic feeding

A

minimal administration of EN <20% requirements to preserve gut integrity rather than nutrition
- preserves epithelium
- prevents translocation
- enhance immune function

permissive underfeeding is deliberately administering < 70% of target calories.

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10
Q

Parental nutrition

A

IV administered sterile nutrients
central access due to risk of thrombophlebitis and infection
lipid triglycerides 40% non protein calories
carbohydrates mainly glucose 60%
all essential amino acids
electrolytes
trace elements and vitamins separately
late day 8 plus probably better than early

protein increased supplementation in burns, trauma, neck fas
decreased in hepatic encephalopathy

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11
Q

stress ulceration

A

stress mediated mucosal injury can be caused by critical illness, maybe due to hypoxia, hypo perfusion, coagulopathy
deep ulcers may cause haemorrhage or perforation
compared to PUD - usually affects gastric fungus and is painless

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12
Q

GI bleeding in critical care

A

highest risk
- mechanical ventilation without EN
- CLD
High risk
- coagulpathy
Mod risk
- mechanical ventilation with EN
- AKI
- Sepsis
- shock
Low risk
- steroids
- anticoagulants

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13
Q

stress ulcer prophylaxis

A
  • enteral feeding
  • pharamcoglocial prophylaxis (PPI / H2)
    • if high or highest risk
    • avoid f low risk of bleeding - increase bacterial overgrowth and HAP (potentially also CDI)
  • cautious vasopressors
  • optimised fluid status
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14
Q

Plasmaphoresis vs PLEX

A
  • Aphoresis - removal of component of patients blood using extracorporeal circuit
  • plasmapheresis - type of aphorises removing plasma
  • plasma exchange - plasmapheresis and replacement with substitute - removing high molveculr weight substances causing pathology. 100-150% of plasma exchanged, often 5 exchanges. 5% HAS replacement

other therapeutic aphorises
- leucopheresis
- thrombocytaphoresis
- erythrocytaphersis (severe malaria, sickle cell crisis, polycythaemia ruby vera)
- rheaphoresis - separate high molecular weights

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15
Q

how does plasmaphoresis work?

A

two methods
- centrifugation - blood spins to separate components by density. used in donation
- filtration - blood passes through specialised filter to separate components - similar set up to RRT, can be adapted for PLEX with replacement fluid given back to bloodstream

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16
Q

Indications for PLEX

A

Category 1
- Neuro - GBS, acute MG, NMDA encephalitis
- Renal - ANCA-vasculitis, anti-GBM, GPA
- Haem - TTP, catastrophic APLS
- Post transplant - desensitisation in ABO incompatibility
Category 2
- Neuro - ADEM, LEMS, MS, VGKC disease, chronic MG
- Renal - amyloidosis
- Haem - AIHA
- Transplant - antibody mediated rejection
- Other - thyroid storm, SLE severe complications

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17
Category IV (ineffective / harmful) PLEX
- ALS - Rheumatoid arthritis - schizophrenia
18
Complications of PLEX
- dilution coagulopathy - complications of access - transfusion reaction - fluid imbalance / hypovolaemia - complications of anticoagulation - drug dose alterations
19
post-intensive care syndrome
constellation of physical and psychological syndromes affecting patients following intensive care stay - physical - weakness, pain, reduced mobility, breathlessness - mental health - PTSD, anxiety, depression - cognitive - memory loss, difficulty concentrating
20
Sequelae of critical care admission
RESP - laryngeal injuries, voice changes, stenosis. Pulmonary hypetension, embolism, fibrosis, long term trachesotomy CVS - LV / RV dysfunction RENAL - AKI, CKD, RRT dependence NEURO - seizures, HII, focal deficit, cognitive deficit NUTRITIONAL - appetite loss, dysphagia PHYSICAL - ICUAW, joint pain, pressure sores COMMUNICATION - difficulties PSYCHOLOGICAL FATIGUE CHRONIC PAIN
21
Identifying rehab needs
prevention e.g. minimises IPPV Screening - within 4 days, prior to discharge, on the ward. PICCUPS tool / Chelsea critical care assessment tool
22
Considerations when assessing critical care related morbidity
- LOS - Severity of illness - Severity of longterm injury e.g. neurology - premorbid respiratory and physical function - nutritional issues - psychiatric e.g. recurrent nightmares, intrusive thoughts, hallucinations
23
Rehab goals
short, medium, long term achievable and can change regular assessment and MDT e.g. goal of early mobilisation early - sit on edge of bed with support medium - stand aided long - march on spot
24
Handover from critical care
Summary of stay including management and diagnosis monitoring and investigation plan plan for ongoing treatment individualised rehab programme
25
Discharge from hospital
Discussion about - physical and cognitive recovery - psychological and emotional recovery - diet - continuing treatment
26
follow up of critical care patients
- more than 4 day admission should be followed up at 2-3 months - assessment of new physical and non-physical problems - rate of recovery - social care / equipment - arranging support
27
Sepsis 3 definitions
Sepsis = life threatening organ dysfunction caused by deregulated host response to infection septic shock = vasopressors needed to maintain MAP > 65 and lactate > 2. 40% mortality
28
SOFA score
6 organs 0-4 0 - 24 2 + = organ dysfunction = 10% mortality Resp = P/f CVS = MAP, vasopressors Neuro = GCS Renal - creatinine, UO Coag = platelets Liver = Bili correlates with mortality e.g. initial score 4-5 = 20% > 12 = 95%
29
Glycocalyx
layer of proteoglycans and glycoproteins semi bound to capillary wall. semi-permeable layer, allows passage of anions and small molecules. manages mediators such as NO injury --> permeability alteration in starling forces and pro-inflammatory pathways.
30
Pathophysiology of sepsis
Cascade of vicious cycles initially PAMPs on microbe activate immune system via TLRs transcription of pro inflammatory cytokines TNF, IL-1B adhesion molecules, acute phase proteins, pro-oxidants pro-coagulant released systemic injury when threshold exceeded by inflammatory response - ROS - damage cells and DNA - Complement
31
Surviving sepsis campaign 1 hr bundle
- measure lactate - take cultures - give abx - administer 30ml/kg fluid if hypotensive or lactate > 4 - vasopressors if remains hypotensive Timing of abx - immediately if definite or probable sepsis or possible sepsis with shock - possible sepsis without shock - 3 hours
32
circulatory failure in sepsis
30ml/kg fluid < 3 hrs if hypo perfusion or shock NA MAP > 65, peripheral if no cvc consider VP if > 0.3mcg/kg/min if cardiac dysfunction consider dobutamine add steroid if ongoing requirements > 4 hrs
33
Early goal directed fluid therapy evidence
rivers 2001 - target MAP, CVP, ScVO2. significant improved mortality Process, arise, promise - no difference Rivers protocol - 1st 6 hrs - supplemental O2 - CVP 8-12 - MAP 65-90 - SCVO2 > 70% - If < 70% - red cell transfusion if Hb < 100 or dobutamine
34
MAP targets evidence
SEPSISPAM - MAP 65-70 vs 80-85. no difference in mortality. less AKI in higher group with chronic hypertension 65 - 'permissive hypotension' MAP 60-65 in over 65s vs usual care. mean 66.7 vs 72.6. no difference in mortality. Chronic hypertensives faired better with lower MAP.
35
Vasopressin evidence
VASST - add vasopressin to noradrenaline, no difference in mortality.
36
Activated protein C
PROWESS - improved mortality concern re bleeding events PROWESS-SHOCK - no improvement. withdrawn
37
Evidence against in sepsis
starches terlipressin vitamin C - CITRIS-ALI - no difference - LOVIT - increased mortality
38
Multi-organ dysfunction syndrome
2 or more organ systems altered function during acute illness such that homeostasis cannot be maintained genetics, comorbidity, iatrogenesis, inflammation severity depends on nature of insult, pre-existing organ reserve, therapies
39
PRIS
Condition associated with propofol use acute bradycardia plus - metabolic acidosis (86%) - rhabdomyolysis (45%) - lipaemia (15%) - enlarged fatty liver
40
PRIS ECG
Brugada like changes coved STE V1-3 Arrhythmias Bradycardia --> systole
41
PRIS pathophysiology
imbalance of energy demand and utilisation oxidative phosphorylation and FFA utilisation are impaired leading to lactic acidosis and muscle necrosis propofol contributes to lipid load and negative chronotropy
42
risk factors PRIS
high sedation requirements - TBI, sepsis high endogenous catecholamine, glucocorticoids low carb-lipid ratio children have lower glycogen stores and high dependence on fat metabolism
43
management of PRIS
stop propofol pacing / chronotropy adequate carbohydrate load RRT prevention - propofol < 4mg/kg/hr - sedation holds - monitor CK and triglycerides
44
delirium
acute, fluctuating, reversible disturbance in cognition and consciousness characterised by disorientation and inattention 29% on ICU increased LOS, mortality, hospital acquired complications
45
delirium types
hyperactive - heightened arousal, restless, agitatied hypoactive - somnolescent, withdrawn, quiet mixed - alternating between two other features - inattention - delusions, hallucinations - sleep wake cycle disturbance
46
risk factors
patient - age > 65 - alcohol - pre-existing cognitive dysfunction - sensory impairment illness - severity - infection / sepsis - hypoxia, hypotension - constipation - pain management - drugs e.g. benzodiazepines, opioids, steroids environment - lack of sleep - lack of day-night routine
47
diagnosis of delirium
4-AT AMTS CAM-ICU - altered mental state or any fluctuation - inattention - squeeze letter A CASABLANCA - Altered level of consciousness RASS other than 0 - Disorgenised thinking - questions / commands 1 + 2 + 3/4
48
management of delirium
prevention - regular assessment - sleep - wake - sleep hygiene, avoiding medications, eye masks, ear plugs - avoid constipation - minimise sedation - analgesia - avoid hypotension, hypoxia - avoid causative medications conservative - re-orientation - family present - early mobilisation - removal of lines pharmacolgical - management of agitation or psychosis - antipsychotics - clonidine - Benzes if alcohol
49
ICU-AW
Secondary muscle weakness occurring after critical illness symmetrical, generalised, proximal weakness with low tone affecting limbs, respiratory muscles and sparing facial and oral muscles - polyneuropathy - polyneuromyopathy - myopathy
50
pathophysiology ICU-AW
muscle atrophy - immobilisation, disuse, unloading, denervation muscle dysfunction - microcirculatory, structural alteration neuropathy - oedema, microvascular dysfunction
51
risk factors icu-aw
patient - older, frailer, obese disease state - duration, severity, mechanical ventialtion, sepsis, MOF - hyperglycaemia Medications - steroids, NMB, sedation
52
diagnosis
clinical - MRC < 48/60, hand dynamoterey, 6mwt electrophysiological - CMAP / SNAP muscle biopsy respiratory weakness - max insp.exp pressure
53
lagophthalmos
incomplete closure of eyes - exposure keratopathy - corneal abrasion
54
eye infections
systemic fungal infection - affect eye and lead to visual loss conjunctivitis - red and sticky eye, bacterial, viral. chloramphenicol eye ointment microbial keratitis - HSV, bacteria - red watery sticky endogenous endophthalmitis - red eye in septic patient, haematogenous spread
55
Non-infective eye issues
ischemic optic neuropathy - hypotension, CRAO acute glaucoma chemises
56
Poisoning presentatoions
accidental intentional recreational suspect in undifferentiated - altered consciousness - respiratory depression - cardiovascular instability - vomiting - seizures
57
Cholinergic toxidrome
Pupils: miotic Neuro: Sedation, seizures Vitals: hypotension, bradycardia Other: diaphoresis, SLUDGE Causes: nerve agents, neostigmine, organophosphate
58
Anti-cholinergic toxidrome
Pupils: myriatic Neuro: agitation or sedation, seizures, clonus Vitals: tachycardia, hypretension, hyperthermia Other: urinary retention Causes: antihistamines, TCA, hyoscine, parkinsons medications
59
Sedative toxidrome
Pupils: Miotic Neuto: sedation Vitals: hypoventilation, hypotension, hypothermia, bradycardia Other: constipation Causes: opioids, alcohol, Benzes, barbiturates, GHB
60
Stimulant toxidrome
Pupils: mydriatic Neuro: agitation, seizures, tremor Vitals: tachycardia, hypertension, hyperthermia, hyperventilation Causes: cocaine, amphetamine, theophylline
61
reduce effect of poisons
reduce absorption - activated charcoal - decontamination - emesis, lavage, whole bowel - lipid sink - LAST - skin decontamination enhance elimination - IV fluid - extracorporeal - urinary alkalisation neutralise - antidotes
62
Extracorporeal removal of toxins
low protein binding, low Vd, low molecular weight < 10kda dialysis < 25kda filtration
63
drugs cleared by RRT
Haemodialysis (most) - salicylates - lithium - carbamazepine - metformin - valproate - alcohols - aminoglycosides - theophyllines Haemofiltration - lithium - opioids - sympathomimetics
64
Specific antidotes
Opioids - naloxone Benzos - flumazenil Beta blocker - glucagon cyanide - hydroxycobalamin toxic alcohols - fomepizole / ethanol Serotonin - cyproheptadine Paracetamol - NAC Digoxin - Digibind
65
TCA Overdose
Anticholinergic toxidrome Dysrhythmias (Na channel blockade) Hypotension Seizures Delirium
66
ECG in TCA overdose
- Prolonged QRS (> 100 - seizure risk > 160 VT) - Prolonged QT - Sinus tachycardia - Right axis deviation
67
Management priorities in TCA OD
General - Toxbase - Airway protection - seizures, loss of airway reflexes - High flow O2 - CVS support - IV access, fluid, cardiac monitoring, vasopressors - Seizure tx - benzodiazepines Specific - Na Bicarb - QRS > 100, seizure, hypotension
68
Antipsychotic OD
Management principles - Benzodiazepines for agitation - supportive care - intubation - delirium on emergence Typical Antipsychotics (haloperidol) - fluctuant mental state, CNS depression, hypertension, tachycardia, anticholinergic Atypical antipsychotics (olanzepine, risperidone) - respiratory depression, CNS depression, hypotension Lithium - Neuro - fine tremor, ataxia, nystagmus, myoclonus, seizure, coma - GI - N, V, D - CVS - bradycardia, hypotension, long QT
69
Mx lithium toxicity
narrow therapeutic index - may be precipitated by polypharmacy, altered physiology - lithium levels, renal function fluid repletion dialysis - level > 4-5 acutely, 2-3 chronically - neuro decompensation - renal dysfunction
70
challenges of illicit drug use
common - 10% 16-60yr olds presentation - covert, secondary. lethality of overdose, contamination of substances pharmacological - unpredictable dynamics, infections with prescribed, evolving chemical substances others - behavioural -aggression, intoxication - capacity issues - concomitant psychiatric conditions - social issues - complications of long term use - vascular access, abscess, manutirition
71
drug of abuse classification
by desirable effect - narcotics - heroin - sedatives - alcohol, benzodiazepines, barbiturates, GHB - stimulant - cocaine, MDMA - hallucinogenic - mushrooms, acid, ketamine - anabolic - steroids recreational, therapeutic, physical or psychological dependencea
72
approach to agitated intoxicated patient
pragmatic approach, unclear diagnosis maintain safety - security assessment of capacity / compliance with mx de-escalation strategies extreme agitation (threat to self or others) - rapid tranquillisation - GA e.g. facilitate CT manage underlying cause of agitation - urinary retention - cocaine / MDMA - benzos manage complications - serotonin syndrome
73
unconscious intoxicated patient
conscious state, pupils, reflexes, airway protection intubation - risk of aspiration, failure of gas exchange, MODS thiamine if risk of wernickes encephalopathy causes - ethanol, toxic alcohols - opioid - other overdose Rule out DDX - meningoencephalitis, sepsis, myxoedema, ICH
74
Alcohol intoxicaion
disinhibition, stupor, coma complications - dehydration, hypoglycaemia, ketoacidosis, lactic acidosis, hypokalaemia, dysrthyhmias
75
toxic alcohols
can be screened for, or treated if clinical signs and symptoms
76
Ethylene glycol toxicity
- antifreeze, detergents - alcohol dehydrogenase --> glycoaldehyde --> oxalic acid - toxic metabolites cause effects - calcium oxalate precipitates in kidney and brain stage 1 - 30mins - 2hrs - similar to ethanol toxicity + coma, seizures stage 2 12-24hr - myocardial dysfunction, MODS stage 3 24-72hr - AKI stage 4 72hr + - cranial nerve defects
77
methanol toxicity
- antifreeze, wiper fluid, paint remover - home distillation - alcohol dehydrogenase to formaldehyde --> formic acid 0-6hr- similar to ethanol 6-30hr - latent phase 6-72hr - visual symptoms (blurring, snowstorm, blindness) seizures, coma, cerebral oedema
78
isopropyl alcohol
hand sanitisers, antiseptic metabolised by alcohol dehydrogenase to acetone isopropanol - direct toxic effects from GABA agonism profound intoxication - haemorrhage gastritis, cerebellar signs, coma
79
toxic alcohol treatment
bicarb - pH 7.35-45 (alkalisation of urine, enhances elimination) cofactors - pyridoxine, thiamine fomepiazole - competitive antagonist of alcohol dehydrogenase - 15mg/kg - serum concentration > 20mg/dl or - osmolar gap > 10, pH < 7.3, HcO3 > 20 haemodialysis - concentration > 50 - pH < 7.25 - visual disturbance, AKI, refractor electrolyte abnoramlity osmolar gap = difference between calculated (2xNa + urea + glucose) and measured osmolarity.
80
GHB
Gamma hydroxybutyrate euphoria, CNA and respiratory depression, rapidly eliminated
81
features in common with toxic alcohol poisonings
high anion gap high osmolar gap rapid absorption metabolites and unchanged drug cleared by kidneys all cause inebriation
82
Serotonin syndrome
altered mental state autonomic instability neuromuscular excitability serotonin produced from metabolism of tryptophan - neurotransmitter, then reupatke and inactivated by MAO thermoreception, behaviour, attention, platelet aggregation mechanisms - excessive formation of precursors (LDOPA) - increased released - cocaine, MDMA - receptor stimulations - TCA, pethidine, fentanyl - decreased reuptake _SSRI, tramadol - decreased metabolism - MAOI
83
serotonin syndrome presentation
benign --> life threatening Altered mental status - confusion, agitation, delirium Neuromuscular excitability - clonus, Hyperreflexia, hypertonia, tremor, rigidity Autonomic - Labile BP, flushing, diaphoresis, hyperthermia high index of suspicion - hunter serotonin toxicity criteria - 1 feature + history of serotniergic agent
84
DDX serotonin syndrome
- thyrotoxicosis - MH - heat stroke - NMS - sedative withdrawal
85
Neuroleptic malignant syndrome
systemic deficit in dopamine idiosyncratic reaction to neuroleptics or withdrawal of dopamine agonists tetrad - altered mental state - rigidity - autonomic instability - hyperthermia compared to serotonin syndrome - more rigidity, Hyperreflexia are. catatonia, encephalopathy, coma. insidious onset. rhabdo and MODS supportive mx, benzos, dantrolene
86
calcium channel blocker OD
elongating preparations, concomitant CVS disease can lead to refractory hypotension as well as bradycardia, heart block, multi-organ hypo perfusion - vasoactive agents - catecholamines - calcium chloride - vasopressors - metaraminol - hyperinsulinaemic euglycaemic therapy (HIET) - high dose glucagon general - echo (pump failure vs vasodilation), early intubation, decontamination if modified release
87
HIET
useful in myocardial dysfunction intracellular transport of substrate and oxygen might help weaning of high dose catecholamine infusions - bolus 1unit/kg insulin following 1unit/kg/hr, titrated up to 10unit/kg/hr - 50% dextrose 50-100ml concurrently followed by 1ml/kg/hr - close monitoring glucose with moderately high target. titrate to BP > 90 HR > 60 maye also be used in severe beta blocker OD
88
Beta blocker OD
Glucagon and milrinone - indirect sympathomimetic effects (not reliant on beta receptors) increased myocardial cAMP positive iontrotopr and chronotyopu bradycardia and myocardial suppression more likely to respond than vasodilation
89
salicylate toxicity
respiratory alkalosis before HAGMA nausea vomiting tinnitus seizures, hypotension, low GCS. hyperthermia urinary alkalisation with bicarbonate 500mg/l mod 750mg/l severe haemodialysis - failure of urinary alkalinsation - end organ impairment - > 1000mg/l
90
digoxin toxicity
- narrow therapeutic index GI symptoms then CNS (chronic - progressive CNS) GI - N/V/D/pain CVS - bradycardia, AV block, AF, junctional, bigeminy neuro - visual disturbance, delirium, sieuzres digoxin specific Ab
91
LAST
early - dysphoria, tinnitus, perineal numbness, metallic taste CNS - agitation, LOC, seizures CVS - heart block, bradycardia, systole, VT
92
Mechanisms of LAST
systemic absorption / IV injection affected by agent, dose, patient interference of conduction in heart and brain risk factors - long acting - more vasoactive agents - bupivacaine vs levobupivacaine - proximal block - use of adjuncts - bilateral blocks
93
Reducing risk of LAST
pre-procedure - assessment, dose calculation procedure - USS, aspiration, serial injection post-procedure - labelling of catheters, NRFiit institutional - availability of lips emulsion
94
Mx LAST
- stop infusion - ABC - lipid emulsion - hyperventilation - seizure managagement - benzo, porropofol - antiarrhythmics as usual - e-cpr Intralipid 20% dose 1.5ml/kg bolus 15ml/kg/hr infusion repeat bolus 3x max dose 12ml/kg
95
corrosive ingestion
acid / alkali readily available airway compromise, GI perforation, strictures decontamination, airway intervention, endoscopy
96
acute heavy metal ingestion
GI irritation - N/V/D, fluid loss, electrolytes and dose related systemic toxicity iron - ALF, cirrhosis Lead - encephalopathy arsenic - hypersalivation, encephalopathy, peripheral neuropathy pro kinetics, endoscopy iron - chelation with dexferrioamine arsenic - chelation with succimer
97
chemical weapons
nerve agents - organophsphares irreversibly bind to anticholinesterase - cholinergic toxidrome managed with anticholinergic infusion, cholinesterase reactivator - pralidoxime cyanidses - impair aerobic respiration, severe refractory lactic acidosis. supportive oxygenations, hydroxycobalamin
98
acute radiation syndrome
whole body irradiation significant history and lymphopenia dose dependent - large dose, external, penetrating, delivered over short time prodrome, latent, manifest illness, death or recovery manifestations - bone marrow destruction - GI destruction - CVS . CNS syndrome management - supportive, treat contamination, lymphocyte count expectant management and palliative care
99
mental health and critical care
common admission repeat admissions evolving medications complex polypharmacy ECT dilirium and withdrawal symptoms refusal of medical interventions need psychiatric follow up may need detention under mental health act