HM Exam 2 Cards Flashcards
Hypoxemia
Low PaO2 while Hypoxia is low oxygen in the tissies
4 in hospital mechanisms causing hypoxemia
Hypoventilation
V/Q mismatch
Right to left shunt
Diffusion abnormailties
3 Indications for starting on oxygen
PaO2 under 60
Sat under 90%
RR over 24 bpm
Inadequate ventilation
May be due to obstruction
Head tilt and chin lift to open airway
Jaw thrust for C spine injury
Easier airway to put in
Nasopharyngeal airway
Also better tolerated
Bag mask technique
Squeeze over 1 second with 10-12 breaths per minute
COPD noninvasive ventilation
BiPAP - helps remove retained CO2
Noninvasive ventilation for OSA or asthma
CPAP
When NOT to use a BiPAP/CPAP
Altered mental status
Unable to handle secretions
Reasons to intubate
Unable to maintain a patent airway
Anticipation deterioration - stroke, overdose
Rapid sequence intubation
Defined by simultaneous administration of a sedative and paralytic agent to assist in endotracheal intubation
Minimizes aspiration and stomach inflation
Bag Valve Mask Ventillation
Effective bridge prior to intubation - required before paralytic agents given
Endotracheal intubation
Airway control established through direct laryngoscopy and orotracheal intubation
5 Indications for mechanical ventilation
Obtunded patient
Hypercapnic respiratory failure
Hypoxemic respiratory failure
CV distress
Expectant
4 phases of mechanical ventilation
Initiation - opening of inspiratory valve
Delivery - Air flows from ventilator to patient
Termination - Closure of inspiratory valve
Exhalation - Air flows back to the ventilator
Controlled breaths
Triggered by the ventilator, cycle set by ventilator - brain dead patients
Assisted breaths
Patient triggers breaths, but the machine sets the cycle
Spontaneous breaths
Trigger and cycle set by patient
Disease criteria to begin ventilator weaning
Improvement of disease process that allows patient to support own respiratory function
Neurological criteria for ventilator weaning
Patient alert, following commands, able to initiate a breath
Respiratory criteria for ventilator weaning
Oxygen requirement of FiO2 40% or less and PEEP 8 or less
Cough can clear secretions at least every 4 hours
Cardiovascular criteria for ventilation weaning
Hemodynamically stable with minimal inotropic or vasopressor support
Extubation protocol
After successful spontaneous breathing trial
Patient should be sitting up and tube should be removed quickly
Where should the ET tube be on a CXR
Just a bit above the carina - not into the right mainstem bronchus
3 goals of oxygen therapy
Increase alveolar oxygen tension
Decrease required ventilatory work
Decrease myocardial work
FIO2
Concentration of oxygen delivered to the patient
Rebreathing system
Used in anesthesia - conserves anesthesia gasses
Expensive
FiO2 range for high flow oxygen
24-100%
High flow rate devices
Patient’s only supply of air
MC - Venturi mask or nebulizer
COnsistency with temp and humidity control
Low flow devices
21-90% FiO2 range
Diliuted by room air
T tube, Nasal Cannula, Simple mask
1 L/m NC FiO2
24%
2+L/m NC FiO2
2 - 28% - increases by 4 with each additional liter (6 - 44%)
Simple mask L/min to FiO2 conversion
5-6 = 40%
6-7 = 50%
7-8 = 60%
Bag mask L/min to FiO2 concetnration
Starting with 6 multiply by 10 for FiO2 (10L is 99.9%)
SIRS criteria
Temp over 38 or under 36
HR over 90
RR over 20
WBC over 12,000 under 4,000 or 10% bands
How many SIRS criteria are needed
2 criteria
Sepsis criteria
SIRS with a source of infection
Overall mortality of sepsis
17.9%
Severe sepsis
Sepsis with one or more signs of organ dysfunction not already present
OR
Resistant hypotension (Under 90 or decrease 40 from baseline)
OR
LDH over 4
Mortality rate for severe sepsis
20-40%
Septic shock
Refractor hypotension (after 3L) with MAP under 65
60% mortality rate
MODS
Multi-Organ-Dysfunction-Syndrome: Results from burns, infection, etc.
Early manifestations of sepsis - 3
Tachycardia
Oliguria
Hyperglycemia
Common infection source for sepsis
UTI - gram negative
Skin/Soft Tissue - Staph
Resp tract - S pneumo, Pseudomonas
Where does staph like to colonize from the blood stream
Heart valve
Spine
Late manifestations of sepsis
ARDS
Acute lung injury
Renal Failure
Hepatic dysfunction
Obtaining blood cultures
Get two -test the second if the first grows gram positive rods (may have been contaminated
Stabilization of septic patient
Oxygen and prtect airway
Central line for pressors
Labs - CBC, CMP, Lactate
Monitoring requirements for sepsis
Sepsis - Tele
Severe and Shock - ICU
3 treatment principles for sepsis
Early resuscitation
Early abx
Early source identification
Sepsis empiric abx without pseudomonas
Vanc and Zosyn
Sepsis empiric abx for pseudomonas coverage
Vanc (if MRSA concern), Zosyn and Cefepime
Quickest way to deal with an abcess
Drain it
Indications to consider antifungals for sepsis tx
Recent abdominal surgery
TPN
Chronic steroid use
Alternative abx that cover pseudomonas
Ceftazidime
Meropenem
Cipro
IV fluids for sepsis
NS or LR
20-40 cc/kg fluid challenge
Monitor CVP trends
3 patients who may have an abnormal baseline CVP
PAH
Dilated CM
RV infarct
Sepsis fluid resiscitation goals
CVP of 8-12 cmH2O
CV SO2 of 70%
Urine output over 0.5mL/kg/hr
Transfusion threshold for blood
7g/dL or less for hgb
First line vasopressor
Norepi - goal of 65 MAP
Nutrition in sepsis
Increased catabolism - supply calories early
Start enteral feedings as early as 48 hours
MODERATE glycemic control (more tight in diabetes
Glucocorticoids and sepsis
If adrenal glands not adequately responding
Under 7 day course allowed
Blood glucose goal for sepsis
140-180 mg/dL
Common kidney injury with sepsis
Acute tubular necrosis
When can a septic pt leave the ICU
Off pressors
No need for invasive monitoring
Not intubated or needed mechanical ventilation
When can a sepsis patient be fully discharged
Mild sepsis that resolves quickly
May need to go to rehab first
4 patients with lower threshold for sepsis evaluation
HIV
Asplenia
Neutropenia
On immune suppressors
3 ways to lower sepsis risk
Urinary catheter removal
CVC removal
Early extubation when possible
Patient safety
Freedom from accidental medical injury
Near miss
Event that could have caused injury but did not
2 Vulnerable patients to medical error
Elderly - Frailer
Pediatric - Difficult to dose
Human based medical error
Will occur - errors of execution or planning
Elements humans can hold in short term memory
7 +/- 2
Impact of fatigue on performance
Similar to having a blood alcohol level of 0.1%
System based errors
May facilitate poor quality of care
Error in the tech side of things
CLABSI
Central Line Associated Bacterial Infections
Prolong hospitilization up to 3 weeks
True definition of cellulitis
Goes down to the derma layer
Risk reduction for intravascular catheter infections
Use subclavian sit if possible
Avoid jugular and femoral sites
Use aseptic technique
Disinfectant for intravascular catherter use
2% chlorohexadine
70% alcohol for hubs
Areas where 60% of pressure ulcers occur
Greater trochanters, Heel, Sacrum, and coccyx
Prevention of decubitus ulcers
Document any on admission
Rotate every 2 hours, every 1 if seated
Every 4 hours for some specialty beds
Braden scale
Scale for risk assessment (18 is cutoff for risk with 6 being highest risk)
MC adverse events in acute care
FALLS!!
Population with higher incidence of falls
65 years+
RF’s for falls
Hx of falls
Dementia/Sundowning
Balance deficits
BZD use
Prevention for falls
Orient all patients to environment
Traction Socks
Bed alarm
Bright lights
Virchows triad
Hypercoagulability
Venous stasis
Vessel injury
Who gets DVT prophylaxis
Consider risk factors - no algorythm (usually everybody gets it)
DVT prophylaxis pharm
Lovenox or Heparin
Heparin has to be given more frequently
Lovenox may cause kidney injury
Non pharm DVT prophylaxis
TED hose or SCIDS
Bleeding with DVT prophylaxis
Very low risk of occurring - monitor daily for signs
Especial care in those with HIIT hx
3 Drug classes that cause constipation
Opiates
Anticholinergics
Iron supplements
Stimulant laxatives and use
Senna or Bisacodyl
For SEVERE consitpation
Osmotic laxatives and use
Lactulose, Polyethylene glycol, Magnesium salts
For mild constipation
Polyethylene glycol (miralax) is best
Stool softener use
Docusate - for prevention not tx of constipation
One thing to rule out in constipation
Bowel obstruction
Definition and Common causes of diarrhea in the hospital
More than 200g per day of fecal matter
Infectious - Bacterial, viral, protozoal
Medications
New Pathology
Tx for C diff diarrhea
Metronidazole or Vanc (technically metro for mild and vanc for others)
4 Abx that cause C diff
Clinda
Cephalosporins
FQs
PCN
Onset for C diff
5 or more days after abx cessation
Indication for fecal transplant for c diff
3rd recurrence
Non abx medications that can cause diarrhea - 4
PPI
NSAIDs
Quinidine
Levothyroxine
Management for new diarrhea
NPO
IV fluids
Avoid antidiarrheal in infection
Cipro for infectious
4 medications that can cause delerium
Antihistaminesand other anti’s
Immune modulators
Muscle relaxers
H2 blockers
Things to rule out for delerium
UTI
Neuro issues
Tx for delerium - non pharm
Orient
Reduce overstimulation
Reduce restraint use
Mobilize early
Sleep wake cycle
Pharm for delerium
Avoid BZD use
Antipsychotics - SL review EKG first
Tx for insomnia
Avoid adding medication if possible - avoid naps
Safest insomnia med for hospitl
Rozerum - Melatonin agonist
Can also use: BZD, Lunesta, Ambien (lots of side effects)
Pain treated by opioids
Static, Nociceptive (post-surgical
Pain not suited to opioids
Movement related or neuropathic pain
Pain appropriate for NSAIDs
Mild to moderate pain
MSK pain
Tylenol and pain
Bettern for fever than for pain
Tx for pain in the ICU
Morphine or Dilauded
Side effects of opioids in ICU
Constipation
Resp depression
Sedation in the ICU
Most patients sedated for healing
Not a tx for agitation - try other things first
Light sedation is better
Sedation agents in the ICU
BZD, Propafol, Precedex
Propofol for sedation
Agent of choice for brief sedation - under 1-3 day course
BZDs for sedation
For longer term sedation
Presedex for sedation
Less respiratory depression
Short term sedation
Good for ventilator weaning
MOA of Presedex
a-2 receptor agonist - water soluble
Definition for hospital acquired pneumonia
Starts 48-72 hours after being admitted, or 90 after discharge
Ventilator associated pneumonia
48-72 hours after intubation
Agents of choice for tx of vent acquired pneumonia
Vanc and Zosyn
Prevention of ventilator associated pneumonia
Elevate HOB 30-45 degrees
COontinuous aspiration of seretions
Silver coated ET tube
Chlorohexadine wash of oropharynx before intubation
Stress ulcer bleeding in the hospital
Treated with H2 blockers and PPIs
H2 blocker may work faster but PPI is available IV
H2 blockers - 3
Cimetidine, Famotidine, Rantidine
Stress ulcer prophylaxis indications
Resp failure - on a ventilator
INR over 1.5 or platelets under 50,000
Other risk factors (2+)
Risk factors for stress ulcer bleeding that should be considered for prophylaxis
Sepsis
ICU admission over a week
6+ days of GI bleeding
Steroid therapy
Therapeutic hypothermia
Useful in many medical conditions
MC in cardiac arrest after ROSC
Three phases of theraputic hypothermia
Induction -give cold saline
Maintainance - watch for hypotension, hypokalemia, shivering
Rewarming - Done gradualluy
Temperature and time goals for therputic hypothermia
32-34 degrees C
For 12-24 hours
COWS
Clinical opioid withdrawal score - can be used during detox or during treatment
COWS interpretation
0-4 - None
5-12 - Mild
12-24 -Moderate
25-36 - Moderately severe
37+ Severe
MC use for COWS
Buprenorphine induction
CIWA
Score for alcohol withdrawal - Scores 8 or lower do not usually need intervention
Scores greater than 20 often need ICU admission
Timeline to follow with PCP post discharge
1 week
Hippocratic oath
To help, or at least do no harm
Surprise Question
Would you be surprised if the patient died in the next year? - Newer prognosis tool
Prognostic index
Gives and estimate based on various PE findings and conditions
NYHA classifications
I - Ordinary activity dioes not cause undue fatigue, palpitations or angina
II - Ordinary activity causes fatigue, palipitations, or dyspnea
III - Less than ordinary activity causes palpitations, angina, or fatigue
IV - Fatigue, palpitations, dyspnea occur at rest
Assessment questions for prognosis
How much time do you spend lying down or in bed - greater than 50% may indicate a prognosis of 3 months of less
Palliative Performance Scale
Uses 5 observer rated domains for prognosis - good tool
7 aspects of palliative care
Structure and process
Psych aspects
Social and spiritual aspects
Cultural aspects
End of life care
Ethical and Legal
Difference between hospice and palliative care
Hospice = 6 months to live
Palliative care - At any point in disease process, considers whether tx options are more of a burden than a help to pt
