ICU Flashcards
The most common electrolyte disturbance following resuscitation in extensively burned patients is
hypernatremia - even though you are using LR
because this is a consequence of inadequate replacement of insensible water loss.
At the completion of resuscitation, a patient with an extensive burn typically has a serum sodium concentration approaching that of Ringer’s lactate solution 130
Anterior cord syndrome occurs when
the blood supply to the anterior portion of the spinal cord is interrupted.
thoracoabdominal aneurysm repair.
The anterior spinal cord blood supply is
anterior spinal,
intercostal,
lumbar arteries.
This blood supply becomes compromised when ligation of intercostal and lumbar arteries occur.
Anterior cord syndrome is characterized by
loss of motor function below the level of injury,
loss of pain and temp carried by the anterior columns of the spinal cord
preservation of fine touch and proprioception carried by the posterior columns
Brown-Séquard syndrome
hemisection injury to the spinal cord,
relatively greater ipsilateral loss of proprioception and motor function,
contralateral loss of pain and temperature sensation.
sparing.
Central cord syndrome
cervical lesion,
greater motor weakness in the upper extremities
relative sparing of lower extremities, with sacral sensory sensory sparing
Cauda equina syndrome
injury to the lumbosacral nerve roots in the spinal canal
areflexic bowel and/or bladder,
variable motor and sensory loss in the lower limbs.
Posterior cord syndrome
interruption to the posterior spinal artery.
loss of proprioception and vibration sensation only.
Unlike anterior cord syndrome, it is a very rare condition.
It is possible for it to present as Brown-Séquard syndrome.
With aneurysm repair, there is a risk of paralysis due to
compromise of lumbar and intercostal artery blood flow to the
anterior spinal artery, the artery of
Adamkiewicz.
Active expiration is defined as a forced exhalation using what muscles
abdominal wall,
INTERNAL intercostal muscles,
diaphragm.
The internal intercostal muscles are involved in inhalation and chest wall expansion and forced expiration. They assist in expiration by pulling the ribcage down. They do not play a role in relaxed exhalation.
During active expiration, the most important muscles are those of the abdominal wall (including the rectus abdominus, internal and external obliques, and transversus abdominus), which drive intra-abdominal pressure up when they contract, and thus push up the diaphragm, raising pleural pressure, which raises alveolar pressure, which in turn drives air out.
Bottom Line: The primary muscle involved in expiration is the diaphragm. The secondary muscles involved in expiration include the internal and external intercostals, external oblique, internal oblique, transverse abdominal and rectus abdominis.
common side effect of the various topical burn agents
Silver Nitrate - broad-spectrum antimicrobial activity in the treatment of burn wounds.
Due to the need to dilute the solution before application, its topical applications can lead to extravasation of sodium resulting in subsequent hyponatremia.
methemoglobinemia.
Silver Sulfadiazine
transient neutropenia.
Mafenide acetate
absorbed systemically
cause metabolic acidosis through the inhibition of carbonic anhydrase.
Neomycin, Bacitracin, and Polymyxin B
topical ointments that are useful for superficial partial- thickness facial burns.
most common associated side effect of these agents is nephrotoxicity when used on large burns.
Polymyxin B should not be used on large burn areas due to the concern for nephrotoxic effects.
Torsadeselectrolyte disturbances
hypokalemia
and
hypomagnesemia
Treatment of intermittent torsades in stable patients is
correcting any underlying metabolic or electrolyte abnormalities
INCRASE! the heart rate to shorten ventricular repolarization.
Intravenous magnesium sulfate is also effective in treating paroxysmal torsades.
Drugs used to tx pulmonary hypertension
Milrinone acts to increase pulmonary vasculature dilation which can lower pulmonary hypertension.
Milrinone works by blocking the degradation of cyclic adenosine monophosphate (cAMP). Milirone improves pulmonary hemodynamics and right ventricular function in chronic pulmonary hypertension.
Milrinone is a phosphodiesterase type III inhibitor that is used as a contractility agent in patients with cardiogenic shock.
viagra
The indications for a PA catheter include and name contraindicaiton
can yield valuable information in the critically ill patient.
treatment of myocardial infarction,
assessment of fluid status,
evaluation of pulmonary edema or pumonary hypertension,
evaluation of valvular disease
cardiac tamponade,
evaluation of postoperative heart surgery patients.
CONTRAINDICATION:
cardiac arrythmias, swan is arrhythmogenic.
The average total caloric requirements by age:
NEWBORNs in the ICU might need up to 125 kcal/kg/day!!
0-1: 90-125 kcal/kg/day 1-7: 75-90 kcal/kg/day 7-12: 60-75 kcal/kg/day 12-18: 30-60 kcal/kg/day > 18: 25-30 kcal/kg/day
The average protein requirement also varies by age:
0-1: 2.0-3.5 g/kg/day 1-7: 2.0-2.5 g/kg/day 7-12: 2.0 g/kg/day 12-18: 1.5 g/kg/day > 18: 1.0 g/kg/day
Criteria for the diagnosis of ARDS include
an acute onset, bilateral pulmonary infiltrates on chest x-ray,
absence of cardiogenic pulmonary edema (i.e., PAWP <18 mm Hg)
this is NOT absence of cardiac path on echo
hypoxemia (Pao2/Fio2 ≤200)
On the same continuum, ALI is a milder form, with Pao2/Fio2 ranging from 201 to 300.
early Sepsis produces
high output cardiac failure,
SVR is decreased due to toxins that produce vasodilation.
SvO2 should be HIGH because the tissues are unable to extract oxygen from the blood effectively.
The arterial oxygen content is calculated with the formula:
CaO2 =
1.34 x Hgb x SaO2) + (0.003 x PaO2
what type of line has the highest DVT risk
Femoral catheters
list order of lest to greatest infection risk with lines
Sublavian (lowest infection)
IJ
Femoral (highest infection)
In ARDS, three populations of alveoli can be distinguished.
Bottom Line: In acute respiratory distress syndrome (ARDS), the flooding of the alveolar space with inflammatory exudate and other chemical mediators rapidly inactivates alveolar surfactant resulting in collapse of alveoli leading to pulmonary shunting and loss of lung compliance.
normal alveoli which are always inflated and engaging in gas exchange
flooded alveoli which can never, under any ventilatory regime, be used for gas exchange
atelectatic or partially flooded alveoli that can be “recruited” to participate in gas exchange under certain ventilatory regimens.
The recruitable aveoli represent a continuous population, some of which can be recruited with minimal PEEP, and others which can only be recruited with high levels of PEEP.
Ventilation-perfusion (V/Q) mismatch
cause of hypoxemia in pulmonary embolism
increase the p50 of normal hemoglobin
Increased: 2,3-DPG, temperature, PCO2 (incr Hydrogen / decreased pH
Norepinephrine mech
stimulates alpha-1, alpha- 2, and beta-1 adrenergic receptors.
The effect
increased contractility
peripheral and splanchnic vasoconstriction.
Norepinephrine is a common medication used in the treatment of SEPTIC shock.
Acute respiratory distress syndrome (ARDS) first phase is
exudative
protein rich fluid move into the alveolar spaces
Leukocytes will proliferate and cause intrinsic lung injury.
The saturation of alveoli with protein rich fluid results in poor oxygenation.
Acute respiratory distress syndrome (ARDS) The second phase
The second phase is fibroproliferative
associated with fibrosis and collagen formation
This creates a stiff, non-compliant lung, but the process is reversible over time
Acute respiratory distress syndrome (ARDS) he third phase is
The third phase is
resolution
lung tissue will begin remodeling and clearing the pulmonary edema.
Arterial oxygen content is determined by the formula:
CaO2 = (1.34 x Hgb x SaO2) + (0.003 x PaO2).
The most important determinant of Arterial oxygen content
The most important determinant in this equation is the hemoglobin level
1.34 x Hgb
CaO2 = (1.34 x Hgb x SaO2) + (0.003 x PaO2).
The SaO2 and the PaO2 play a smaller percentage in determining the overall content.
A sudden drop in end tidal CO2 upon induction of pneumoperitoneum should raise the suspicion for
a CO2 embolus from the pneumoperitoneum.
Careful, this is paradoxical that endtital CO2 is low with too much CO2 collected in vascular system -> heart!
Managment of A sudden drop in end tidal CO2 upon induction of pneumoperitoneum
Suspect a CO2 embolus from the pneumoperitoneum
First,
the ventilator tubing should checked
treatment for a CO2 embolus
discontinue the pneumoperitoneum,
place the patient in the left lateral decubitus position,
attempt to aspirate the air from a central line in the right atrium.
Hyperventilating can help to diffuse the carbon dioxide.
increase in end tidal CO2 is indicitive of what beside MH and what is treatment
alveolar hypoventilation
Increasing the tidal volume is the treatment for
best choice of topical burn agent with sulfa allergy
Silver nitrate
Although it has limited eschar penetration, of the
Silver sulfadiazine (Silvadene) and mafenide acetate (Sulfamylon) are contraindicated in patients with sulfa allergies
