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Hint Hint Flashcards

1
Q

Causes of increased lactate

A

Seizures, exercise, beta agonist use, infection, shock, alcohol ingestion

Type A: supply/demand imbalance
Type B: clearance problem (e.g. liver), drug induced production (beta agonist, metformin, cyanide), problem with krebs cycle (genetic cause)

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2
Q

Steps to x Ray interpretation

A
  1. Pt identifiers / labels
  2. Type of film
  3. Adequacy (ribs, spine, clavicles)
  4. Tubes and toys
  5. Soft tissues
  6. Bones
  7. Mediastinum
  8. Lungs
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3
Q

MUDPILES

A 
Methanol
Uremia
DKA
Paraldehyde
Iron
Lactate
Ethanol/ethylene glycol
Salicytes
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4
Q

DO2 equation

A

DO2 = CO x CaO2

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5
Q

Arterial oxygen content

A

CaO2 = Hgb x 1.39 x SaO2

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6
Q

Normal ScvO2

A

60-80% (distal port on CVC, SaO2 on EPOC)

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7
Q

IAH

A

Intraabdominal hypertension, end-expiration foley pressure > 12

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8
Q

ACS

A

Abdominal compartment syndrome, decreased organ perfusion, sustained pressure > 20 at end expiration

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9
Q

Parkland formula (BCEHS/VGH specific)

A

3 mL/kg/%BSA,

Give half amount over first 8 hrs

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10
Q

Trauma assessment

A 
Airway
Breathing
Circulation (carotid, femoral, pelvic binder, FAST)
Disability (pupils, GCS, collar)
Exposure, environment
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11
Q

Massive transfusion end points

A 
Hgb > 70
Platelets > 100
INR < 1.8
Temp > 36
Fibrinogen > 1.5
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12
Q

Causes of hypoxemia

A 
Shunt
V/Q mismatch (dead space) 
Hypoventilation
Decreased FiO2
Diffusion restriction
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13
Q

Shunt

A

Perfusion - good

Ventilation - bad

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14
Q

Dead space

A

Perfusion - bad

Ventilation - good

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15
Q

Restrictive lung disease

A

Problems with lung/alveolar expansion (low compliance)

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16
Q

Obstructive lung disease

A

Resistance to air flow within the lungs (high resistance)

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17
Q

Cranial contents

A

CSF
Parenchyma
Blood
Mass effect (tumour)

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18
Q

Spinal cord injury treatment goals

A

Maintain MAP > 85
Adequate ventilation and oxygenation
Hgb > 80
PaO2 > 80

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19
Q

Burn treatment goals

A

SpO2 > 91
MAP > 65
HR < 130

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20
Q

Principles of damage control resuscitation

A

Damage control surgery
Balanced haemostatic resuscitation
Permissive hypotension

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21
Q

What are the principles of balanced hemostatic resuscitation?

A 
Minimize crystalloid use
Prevent acidemia 
Reduce coagulopathy
Keep warm 
Give early blood
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22
Q

Indicators for massive transfusion (ABC score)

A

Penetrating trauma
SBP < 90
HR > 120
Positive FAST

Need 2

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23
Q

Burn goals

A 
Urine output 30-50 mL/hr
MAP > 65
Lactate <4
ScvO2 > 70
Hgb > 70
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24
Q

Tx of abdo compartment syndrome

A 
OG/NG
Ultrasound for potential drain
Proper analgesia (muscle relaxation)
Reverse trendelenburg 
Paralysis
Surgical intervention
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25
Q

West lung zones

A 
1 = V > Q
2 = V =Q
3 = V < Q
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26
Q

Increasing PIP and Plat =

A

Decreasing compliance

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27
Q

Increasing PIP with minimal change in plat =

A

Increasing resistance

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28
Q

Driving pressure

A

ARDS related term
Plat - PEEP
15 is a good goal

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29
Q

Reasons for dysyncrony

A

Trigger
Flow delivery
I:E switch over

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30
Q

What to do on a high pressure alarm

A 
1 check the circuit (kinked)
2 chest motion (pneumonia, r main)
3 suction
4 D/C vent and hand bag
5 check paralysis/sedation
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31
Q

Useful values of VBG

A

pH
CO2 (-15)
HCO3

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32
Q

Berlin criteria

A

Bilateral infiltrates on CXR
Non-cardiogenic pulmonary edema
P:F <300
> 1 week illness

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33
Q

Proning criteria

A

P:F < 150
Optimally ventilated
Dx ARDS

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34
Q

Tx for asthma

A 
Ventolin 5 mg
Atrovent 500 mcg
Methylprednisone 125 mg IV
Mg 2 g IV
Epi 
BPAP to buy time for Rx to work
Intubation with low RR, iTime, PEEP, high flow (ketamine, propofol for RSI)
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35
Q

LFTs

A

Albumin
PT
INR
Bili

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36
Q

Liver enzymes

A

AST
ALT
Alk Phos
GGT

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37
Q

Serum osmolality

A

(2 x Na) + glucose + urea

Normal 280ish

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38
Q

Approach to hypoxemia in ARDS

A 
Increase FiO2
Maximize PEEP
Increase RR
Paralyze
AC to PC mode
Recruitment maneuver
Prone
Ti inverse
ECMO
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39
Q

Causes of hypoxia

A

Anemic
Hypoxemic
Histotoxic
Stagnant

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40
Q

Most effective interventions in reducing ICP

A 
Temp control (parenchyma volume and blood volume)
CO2 (blood volume)
HOB 30 degrees (blood volume)
Loosen ties (blood volume)
EVD (CSF)
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41
Q

Intracranial pressures (normal, abnormal, severe)

A

Normal = 10
Abnormal > 20
Severe > 40

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42
Q

Reasons for decreased ScvO2

A 
Increased extraction
High demand/metabolism
Low O2 supply
Lung/oxygenation problem
Decreased cardiac output
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43
Q

Reasons for high ScvO2

A

Histotoxia
Ischemic tissue
Decreased metabolism
Shunt (May be high or low)

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44
Q

Venous return equation

A

Mean systemic filling pressure - R atrial pressure

/ SVR

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45
Q

Driving pressure

A

Only applicable in ARDS
PPlat- peep

Driving pressure of 15 is a good goal

If you increase PEEP and driving pressure does not increase then you have recruited more lung.

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46
Q

Treatment pathways for hypoxia

A

VQ - edema = PEEP
- pneumonia = position, abx

Shunt = fluid, inotropes, vasopressors

Venous admixture - CO = inotropes
- SpO2 = oxygenation

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47
Q

Causes of fever

A

Infection
Connective tissue diseases
Malignancy

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48
Q

Sepsis end therapy goals

A

ScvO2 > 70
CVP 8-12
MAP > 65
Urine output > 0.5 ml/kg/hr

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49
Q

Sepsis tx algorithm

A
  1. Source control
  2. Early antibiotics
  3. Adequate perfusion
  4. Adjuncts
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50
Q

adequate lactate clearance

A

20% over 2 hrs (lecture)

Or

(Initial lactate - 2 hr lactate) / initial lactate x 100

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51
Q

qSOFA

A

GCS < 15
RR > 22
BP < 100

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52
Q

SIRS criteria

A

Temp 36-38
HR > 90
RR > 20
WBC 4-12

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53
Q

Sepsis

A

2 SIRS

+ confirmed infection

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54
Q

Severe sepsis

A

SIRS x 2
Signs of end organ damage
BP < 90
Lactate > 4

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55
Q

Septic shock

A 
Despite adequate fluid resuscitation BP < 90
2 SIRS
Confirmed infection
Signs of end organ damage
Lactate > 4
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56
Q

Massive PE vs submassive

A

SBP < 90 after fluid resuscitation = massive

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57
Q

How to prevent aspiration during intubation

A 
HOB at 30
Paralytic
Topical anesthetic
Suction ready
NG to aspirate GI contents
Cricoid Pressure
Low tidal volumes with BVM
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58
Q

Obstructive airway diseases

A

Asthma
COPD
CF

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59
Q

COPD exacerbation tx

A 
Oxygen for SpO2 88%
Ventolin
Atrovent q 1 hr
Prednisone 50 mg PO/IV
Arterial line 
Atypical antibiotic coverage
BPAP (unless drowsy, secretions or acidosis)
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60
Q

Rivers EGDT in sepsis

A

CVP 8-12
MAP > 65
ScvO2 > 70
Urine output > 0.5 ml/kg/hr

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61
Q

Preload assessment

A 
CVP (trends, < 6 = give fluid)
IVC collapsibility (RASS -5, paralyzed, in sinus rhythm) 
Pulse pressure variation on art line
Passive leg raise (30-45 sec if 10 pt increase in MAP = give fluids)
ScvO2 (< 70 = give fluid)
JVP
62
Q

Cardiogenic shock algorithm

A
  1. Fix the lungs (intubate, BPAP)
  2. Optimize the MAP (> 65), consider vasopressors/fluid or vasodilators
  3. Consider fluid removal
  4. Consider inotropes in HFrEF (dopamine, dobutamine, milrinone)
  5. Treat underlying etiology (rhythm, MI)
63
Q

Dopamine vs dobutamine vs milrinone

A

Dopamine (mid = inotrope, increased HR) (high = inotrope, increased afterload/SVR)

Dobutamine (inotrope, decreased SVR, increased HR)

Milrinone (inotrope, decreased SVR, no effect on HR)

64
Q

VAP bundle

A 
HOB 30 degrees
Extubation
Subglottic suctioning 
Oral care (including supraglottic suctioning) 
Proper nutrition
65
Q

Obstructive lung diseases definition

A

Conditions that make it hard to exhale all the air in the lungs (high resistance, hypercapneic)

66
Q

Restrictive lung diseases

A

Difficulty fully expanding the lungs with air (poor compliance)

67
Q

Measurement of fibrinolysis effectiveness in STEMI

A

Reduction in STE > 25% within 60-90 mins of administration

68
Q

Wall tension equation

A

(Pressure x radius) / wall thickness

69
Q

Elastance

A

Pressure / volume

How much pressure to recoil

70
Q

Compliance

A

Volume / pressure

Pressure to distend

71
Q

Cardiac output equation

A

EF x EDV x HR

EF = (SV / EDV) x 100

72
Q

Type I MI

A

Occlusive obstruction

73
Q

Type II MI

A

An imbalance between oxygen supply and demand unrelated to acute atherothrombosis

74
Q

Rescue PCI

A

Within 24 hrs of failed fibrinolysis (STE not < 25 % , ongoing pain, arrthymia, cardiogenic shock)

75
Q

Aortic dissection tx plan

A

SBP < 140
Labetalol 20, 40, 40, 80 mg q 10 mins
Hydralazine
Nitrates

76
Q

STEMI for PCI algorithm

A

ASA
Ticigrelor
Heparin

77
Q

STEMI for fibrinolysis algorithm

A 
Within 12 hrs pain onset
ASA
Clopidogrel
TNK
Heparin
78
Q

NSTEMI treatment algorithm

A

ASA
Clopidogrel/ticagrelor
Enoxaparin (12 hrs), fondaparinox (24 hrs), UFH (if renal failure)

79
Q

Gustilo classification

A

Open fracture classification

I - clean wound of < 1 cm in length with simple fracture pattern
II - wound > 1 cm without extensive soft tissue damage and simple fracture pattern
III - wound associated with expensive soft tissue damage (should be given empirical antibiotics)

80
Q

Rules for clearing c spine

A 
NEXUS
D - deficit present
T - tenderness on midline palpating
A - altered LOC
I - intoxicated
L - leg fracture (I.e. distracting injury)

Require above without imaging, otherwise CT and GCS 15, or ALOC and MRI.

81
Q

Crush syndrome vs compartment syndrome

A

Crush syndrome: the systemic manifestations of a crushed/ischemic muscle compartment

Compartment syndrome: increased pressure within a compartment results in insufficient blood supply to tissue within the compartment space

82
Q

Eye vital signs

A 
Visual acuity
Intraoccular pressure
Pupils
Extraoccular movement
Visual fields
83
Q

Venous thromboembolism (penetrating neck wound) tx

A

Left lateral decubitus positioning to prevent air embolism in RV preventing forward flow (RV collapse)

84
Q

Spinal motor exam (deficit levels)

A 
C4 - spontaneous breathing
C5 - shoulder shrugging
C6 - flexion of elbow
C7 - extension of elbow
C8-T1 extension of fingers
T1-12 intercoastal/abdominal muscles
L1-L2 flexion at hip
L3 - adduction (in) at hip
L4 - abduction (out) at hip
L5 - dorsiflexion (up) of foot
S1-S2 plantar (down) flexion of foot
S2-S4 rectal sphincter tone
85
Q

TILE score

A

Pelvic fracture score

Type A - stable, posterior arch intact
Type B - partially stable, incomplete disruption of posterior arch
Type C - unstable, complete disruption of posterior arch

86
Q

Young Burgess classification

A

Pelvic fracture

Lateral compression
Anterior posterior compression
Vertical shear

87
Q

Neck zones

A

I - base of neck to cricoid
II - cricoid to chin-ish
III - chin to base of skull (mostly posteriorly)

88
Q

Ludwig’s angina

A

Bacterial infection that occurs in the deep neck tissues

89
Q

ET tube placement on CXR

A

5 cm above carina

In between clavicles and carina

90
Q

CXR findings in pulmonary edema

A 
Curly b lines
Peribronchial cuffing
Bat wings 
Hilar congestion 
(Cardiogenic will be concentrated around mediastinum whereas non-cardiogenic will be more diffuse)
91
Q

Rigler’s sign

A

In abdo X-ray

Air in bowel combined with free air surrounding bowel creates greater contrast between bowel wall making intestinal structures easier to see (sign of a possible bowel perforation)

92
Q

Steps to assess cervical x Ray

A

A - alignment of 4 lines in lateral view
B - bone
C - cartilage (look for consistent disc spacing)
S - soft tissues (C4 = < 7 mm, C7 = < 21 mm)

Odontoid view = lateral masses should be aligned between C1-C2 and spaces should be equal on both sides

93
Q

Goals in aortic dissection

A

HR approx 60
BP 100-120 systolic

Labetalol
Hydralazine

94
Q

Retroperitoneal organs

A 
Part of duodenum
Ascending colon
Defending colon
rectum
Part of pancreas
Kidneys
Proximal ureters
Bladder
95
Q

Types of fractures

A 
Transverse (straight across bone)
Oblique ( diagonal across bone)
Comminuted (shattered fragments) 
Spiral (around shaft)
Sigmental (floating section of broken bone I.e 2 fractures)
96
Q

CT views

A

Saggital (divides L and R)
Coronal (divides front and back)
Transverse/axial (slices top and bottom)

97
Q

4 A’s of anesthesia

A

Amnesia
Analgesia
Areflexia
Autonomic stability

98
Q

Indications for intubation

A 
Protection
Progression
Oxygenation
Ventilation
Refractory shock
99
Q

Anaesthetics and MOA

A 
Propofol (GABA-A receptor agonist)
Etomidate (GABA-A)
Midazolam (GABA-A)
Ketamine (NDMA receptor blocker)
Opiates (Mu receptor agonist)
100
Q

GABA-A anesthetics and MOA

A

Propofol
Etomidate
Benzodiazepines

Activates post-synaptic GABA-A receptor causing influx of chloride leading to hyperpolarization and reduction in nerve impulse transmission.

101
Q

NDMA anaesthetics and MOA

A

Ketamine

Antagonizes post-synaptic NDMA receptor (responsible for pain and awareness) which stops influx of sodium and calcium and stops eflux of potassium. Other Na/K pumps are still working in neuron which allows the propagation of other neural impulses (I.e. they are still responsive to commands).

102
Q

MOA of opiates

A

Attaches to (primarily) Mu receptor which blocks the influx of Ca in presynaptic neuron.

Also opens K channels on post-synaptic neurons causing hyperpolarization

103
Q

MOA of succinylcholine

A

Binds to post-synaptic nicotinic receptor which mimics the action of ACh and depolarizes cells. Not easily broken down by ACh-esterase therefore it prevents the neuron from depolarizing again.

104
Q

MOA of rocuronium

A

Blocks nicotinic ACh receptor from becoming depolarized

105
Q 
Propofol
RSI
Maintenance 
Onset 
Duration
A

RSI 1-2 mg/kg (0.5 mg/kg if in shock)
Maintenance 30-60 mcg/kg/min

Onset rapid
Duration 10 mins

106
Q 
Midazolam
RSI
Maintenance 
Onset
Duration
A

RSI 0.15-0.3 mg/kg (0.075-0.15 mg/kg)
Maintenance 2-15 mg/hr
Onset 3-5 mins
Duration 2 hrs

107
Q 
Ketamine
RSI
Maintenance 
Pain
Onset
Duration
A 
RSI 1-2 mg/kg (0.5-1 mg/kg if in shock)
Maintenance 1/2 induction dose/hr
Pain 0.1 mg/kg IV
Onset 1 min
Duration 15 mins
108
Q 
Fentanyl
RSI
Maintenance 
Pain
Onset
Duration
A 
RSI 1-2 mcg/kg (0.5-1 mcg/kg if in shock)
Maintenance 25-100 mcg/hr
Pain 25-50 mcg IV
Onset faster than morphine
Duration 30-60 mins
109
Q

Rocuronium
Dose
Onset
Duration

A

1 mg/kg
Onset 1 min
Duration 30 mins

110
Q

Succinylcholine
Dose
Onset
Duration

A

1.5 mg/kg
Onset 1 min
Duration 10 mins

111
Q

Difficult BVM

A 
Bearded
Obese
Old
Toothless
Sounds
112
Q

Difficult intubation

A 
Look
Evaluate 3-3-2
Mouth opening mallanpati
Obese/obstruction
Neck mobility
113
Q

Non-anion gap metabolic acidosis differentials

A

GI loss

RTA

114
Q

TIMI score

A 
Likelihood of ischemic events or mortality with UA/NSTEMI
Age > 65
3 or more CAD risk factors
Known CAD > 50%
ASA use in past 7 days
> 2 episodes of angina in last 24 hrs
ST deviation > 0.5
Elevated trop
115
Q

Killip class

A

I- no signs of congestion
II- s3 / rales
III- acute pulmonary edema
IV - cardiogenic shock

116
Q

Forester class

A

I - warm and dry
II- warm and wet
III- cold and dry
IV - cold and wet

117
Q

Steps to head CT interpretation

A
  1. Pt details
  2. Technique
  3. Orbits and soft tissues
  4. Bones
  5. Brain parenchyma
  6. Ventricles
  7. Midline structures
118
Q

Fisher score

A

Used to estimate the risk of cerebral vasospasm after SAH using CT scan

Group 1: no subarachnoid blood detected
Group 2: thin layer less than 1 mm thick
Group 3: localized clots or layer more than 1 mm thick
Group 4: diffuse or no subarachnoid blood with intracerbral or intraventricular clots

119
Q

Steps of neuro exam

A
  1. Mode of ventilation
  2. Sedation level
  3. Open eyes - is there movement? (CN III, midbrain)
  4. Pupil response to light (CN II, III, midbrain)
  5. Corneal reflex (V, VII, pons)
  6. Gag (IX, X, medulla)
  7. Cough (X, medulla)
  8. Respiratory centre (medulla)
  9. Motor response GCS
  10. Tone (flaccid, rigid, spastic)
  11. Reflexes (biceps C5, wrist C6, elbow C7, plantar)
120
Q

TBI goals

A 
CPP > 60
MAP > 80 (systolic <160)
PaO2 100
PaCO2 35-45
Hgb > 90

Rapid transport for surgical etiology ( epidural, subdural)

121
Q

BP target in ischemic stroke

A

Thrombolytics = 180

No thrombolytics = 220

122
Q

BP target in ICH

123
Q

Signs to intubation in SCI

A 
Nasal flaring
Shoulder shrugging
Sternocliedomastoid muscle use
High RR with normocapneia 
Paradoxical breathing 
(If biceps curl ability present = phrenic innervation intact)
124
Q

MAP target in SCI

125
Q

Indications for prophylactic anti convulsants

A

Penetrating head trauma
Depressed skull fracture
Previous seizure disorder or presentation
Temporal pathology

125
Q

FAST exam RUQ

A

Hepatorenal interface
Pouch of Morrison
Caudill tip of liver
Spine sign

Fan through

126
Q

FAST LUQ

A

Spleno-renal interface
Caudile tip of spleen
Diaphragm and spleen* (at least 9 o clock)

127
Q

FAST pelvis

A

Lateral view of bladder
Front view of bladder
Seminal vesicles should be black
Pouch of Douglas (females)

128
Q

eFAST lungs

A 
Highest point
Lung sliding (shimmering and comet tails)
129
Q

FAST heart

A

Subxiphoid

Look for apex of heart and fan through

130
Q

BP goal in SAH

A

If controlled < 220

If not < 140

131
Q

ACA occlusion

A

Contralateral leg

132
Q

Left MCA occlusion

A

Right face, arm And speech deficits

133
Q

Right MCA occlusion

A

Left face and arm deficits

134
Q

PCA occlusion

A

Contralateral vision problems

135
Q

Basilar artery occlusion

A

Acute LOC, normal pupils, locked-in syndrome

136
Q

Internal carotid occlusion

A

Face, arm and leg deficits

137
Q

Vertebral artery occlusion

A

Poor gag, poor coordination, hemianopsia

138
Q

Occlusive CVA BP goals

A

No thrombolytics < 220

Thrombolytics < 180

139
Q

Symptoms SIADH

A

No urinary output
Dilutionally low Serum Na

Tx free water restriction (except in SAH with hypotension)

140
Q

Symptoms of cerebral salt wasting

A

High urinary output

Low serum Na

141
Q

Central diabetes insipidus

A

Polyurea
Relatively high Serum Na

Tx DDAVP (synthetic ADH)

142
Q

ONSD measurement

A

3 mm down from back of eye

> 6mm = ICP > 15

143
Q

IVC collapsibility

A

1 cm right to midline
Look for hepatic vein draining into vena cava
Measure caudile to hepatic vein
50% indicates fluid replete

144
Q

Dose of NTG and hydralazine in cardiogenic shock

A

NTG 20 mcg/min (100 not uncommon)

Hydralazine 5-20 mg IVP

145
Q

Cardiogenic shock inotrope doses

A

Dopamine mid = 5-15 mcg/kg/min (increase inotropy, increase HR)

Dopamine high = 20-50 mcg/kg/min (increase inotropy, increase SVR)

Dobutamine = 2-20 mcg/kg/min (increase inotropy, decreased SVR, increase HR)

Milrinone = 0.25-0.75 mcg/kg/min (increase inotropy, decrease SVR, no effect on HR)

146
Q

UFH doses

A

Bolus 70U/kg (max 5000U)

Maintenance 12U/kg/hr to PTT 50-75

147
Q

Clopidogrel dose

A

600 mg for PCI

300 mg for fibrinolysis unless > 75 then 75 mg

148
Q

Ticigrelor dose

149
Q

Timeline for rebleeding in SAH

A

Peaks at 7 days

150
Q

Timeline for vasospasm in SAH

A

3-5 days after surgery

151
Q

Indications for mech vent in neuromuscular disease patient

A

FVC < 20 ml/kg
MIP less than -30 cmH2O
MEP less than 40 cmH2O
VC decreased by 30% of normal

CCP 2 (2 decks)

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