Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

RCE 2021 > ICU > Flashcards

ICU Flashcards

1
Q

Types of Shock

A
  1. Sepsis - loss vascular tone
  2. Hypovolemic - loss preload
  3. Obstructive - inc after load (PE, tamponade, constrictive pericarditis)
  4. Cardiogenic - pump failure (ACS, valvular)
  5. Anaphylactic/distributive - SIRS, endocrine, mitochondrial dysfunction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Central venous O2 sat

A
  • Get from CVC (SVC), normal 60-65%
  • Mixed central is from pulmonary artery catheter (SVC and IVC), normal 65-70%

ScvO2 >80% = sepsis
- Cells of body are too sick to extract O2 from blood and blood is in high flow state
ScvO2 <60% = cardiogenic
- Heart can’t pump blood with O2 to cells

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Sepsis and Septic Shock definitions

A
  1. Sepsis - life threatening organ dysfunction by dysregulated host response to infection. Mortality >10%
    - qSOFA score
  2. Septic shock - subset of sepsis with profound circulatory, cellular, metabolic abnormalities. Mortality >40%
    - Lactate >2
    - Need pressers for MAP >65 in absence of hypovolemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

qSOFA score

A 
2/3 of:
1. RR>22
2. SBP <=100
3. Altered LOC (GCS<15)
If positive = think infection
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Surviving Sepsis Categories

A
  1. Initial resuscitation
  2. Abx - empiric broad spectrum
  3. Fluid - crystalloid>colloid, 30 mL/kg bolus
  4. Vasopressors - NE > vaso, epi
  5. Steroids - if refractory septic
  6. Blood - RBC if Hb <70, plt <10 or <50 and bleeding
  7. Mech vent - lung protective ventilation
  8. Adjunctive
    - Bicarb - only pH <7.15
    - Nutrition
    - DVTp
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Sepsis 1st hour

A
  1. Lactate - repeat q2-4 if >2
  2. Cultures
  3. Broad spec ABx
  4. IVF - 30 mL/kg for HOTN or lactate >4
  5. Pressors if HOTN for MAP 65+
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Which fluid for sepsis?

A

Crystalloid (RL) unless CI

  • HyperK
  • Mitochondrial disease
  • TBI
  • Can use albumin in addition if significant amount of crystalloid given
  • No bicarb if pH >7.15
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How much fluids in sepsis?

A
  1. 30 mL/kg in first 4 hours
  2. Then use dynamic measures to determine ongoing needs:
    - NOT CVP
    - Passive leg raise
    - Fluid challenge - inc SV/CO by 10-15% after 250-500 cc
    - Pulse pressure variation
    - Stroke volume variation
    - IVC variation distensibility index - int/vent >15-20% likely, not int >40% likely, low doesn’t mean non responder
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Why do you need to know if your patient is fluid responsive?

A
  1. If you have maximized their preload then giving more fluid won’t help their blood pressure/perfusion
  2. If you give more fluid than they need you risk ARDS, AKI, intra abdominal compartment syndrome
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Vasopressors

A
  1. NE - alpha effect, 0.03-0.35, can add vast or eps
  2. Vasopressin - 0.03 u/min
  3. Epi - increases lactate (can’t use to guide)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Adrenergic receptors

A

Alpha 1 = inc SVR
Alpha 2 = dec SVR (clonidine)
Beta 1 = inc chronotropy (rate), inotropy (contractility), domotropy (conduction)
Beta 2 = relax smooth muscle/GB/uterus, bronchodilator

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Phenylephrine

A

Alpha 1

  • Reflex bradycardia
  • Use in opioid induced HOTN
  • Dec HR and CO, inc SVR and PCWP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Norepinephrine

A

Alpha 1, a bit of beta 1

  • 0.03 - 0.3 mcg/kg/min
  • Inc HR, CO, SVR and PCWP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Dopamine

A

High dose - alpha 1
Low dose - beta 1/2
High risk tachy vs. NE
- Inc HR, CO, SVR, PCWP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Epinephrine

A

High dose - alpha 1
Low dose - beta 1/2
High risk of tachy vs. NE
- Inc HR, CO, SVR, dec PCWP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Dobutamine and isoproterenol

A

Beta 1 and Beta 2

- Inc HR/CO, dec SVR/PCWP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Milrinone

A

Beta 1 and Beta 2

  • NOT in renal failure
  • Very long half life
  • Inc HR/CO, dec SVR/PCWP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Vasopressin

A

Works on its own V1 receptor causing vasoconstriction = inc SVR
Can cause digit and gut ischemia
- Inc SVR/PCWP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Steroids in Sepsis

A

Only if REFRACTORY septic shock- not responding to IVF and pressors
Hydrocortisone 200 mg/day total
- 100 mg loading dose
- 50 mg QID x5-7 d

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Hypoxemic Respiratory Failure - Type 1

A
  • PaO2 <60
  • V/Q mismatch
  • Low FiO2, diffusion, alveolar, shunt
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Hypercapneic respiratory failure - type 2

A
  • PaCO2 >45

- Can be accompanied by hypoxemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Post operative respiratory failure

A
  • Atelectasis, low FRC

- Secondary chest wall/anesthetic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Circulatory collapse respiratory failure

A
  • Shock

- Severe acidosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

HFNC

A
  • Humidified O2, up to 60 L/min
  • AGMP - PPE***
  • May help reduce rates of intubation
    Benefits
  • Dec constriction, inc secretion clearance
  • Dec dead space
  • Dec upper airway resistance
  • Recruit atelectasis
  • Inc FiO2
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

When to use NIPPV

A

Definitely
- Mild-sev acidemia COPD (CO2>45, pH<7.35, RR>20-40)
- Cardiogenic pulmonary edema (excl MI, cardiogenic shock)
Probably
- Post extubation ARF prophylaxis (>65, underlying heart/lung disease)
- Post op ARF (supra diaphragm, GI+eso, pelvic *ensure no concern for anastomotic leak)
- Palliative ARF
- Immunocompromised ARF
DO NOT USE
- Non acidotic COPD
- Failed extubation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

NIPPV Harms

A
  • Delayed intubation
  • Unrecognized deterioration
  • Not lung protective
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Contraindications to NIPPV

A
  • Facial surgery, trauma
  • Dec LOC
  • Can’t clear secretions
  • Respiratory arrest
  • HD unstable
  • Indication for intubation
  • AGMP!!! Watch for COVID
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Goals of mechanical ventilation

A
  1. O2 delivery
  2. A-B homeostasis
  3. Airway protection
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

MV improves oxygenation by:

A
  1. Increasing FiO2 delivered
  2. Reducing VQ mismatch - PEEP opens alveoli
  3. Reduce shunting
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Volume control

A

Trigger: ventilator/time
Target: Flow
Cycle off: volume
Variable: pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Pressure control

A

Trigger: ventilator/time
Target: pressure
Cycle off: time
Variable: volume

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

ACPC

A

Trigger: ventilator +/- patient
Target: pressure
Cycle off: time
Variable: volume

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

ACVC

A

Trigger: ventilator +/- patient
Target: flow
Cycle off: volume
Variable: pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

SIMV

A

Trigger: ventilator +/- patient
Target: varies
Time off: time for variable breaths

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Pressure support

A

Trigger: patient
Target = pressure
Cycle off: flow
Variable: volume and rate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Initial MV Settings

A

Mode: pressure or volume, assist or control
Tidal volume: ARDS 4-8 cc/kg
RR: except for PS
PEEP, FiO2, trigger, cycle off, alarms/backup
Re assess

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

ARDS pathophys

A 
Pathophys:
- Alveolar damage
- Hyaline membrane deposition
- endothelial damage/permeability
Causes:
- Local: PNA, contusion, aspiration
- Systemic: sepsis, pancreatitis, drug, TRALI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

ARDS definition

A
  1. Onset within 1 week of insult
  2. Bilateral opacities on CXR (pulmonary edema)
  3. Not due to cardiogenic/vol overload
  4. PF ratio with PEEP >=5
    a. Mild 200-300
    b. Mod 100-200
    c. Sev <100
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

ARDS Treatment

A
  1. Tx underlying cause
  2. Provide oxygenation
  3. Protect the lungs
  4. ICU best practices
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

ARDS - Lung protective ventilation

A
  1. Tidal volume 4-8 cc/kg (based on predicted weight from height)
  2. Proning in severe for >12 hrs/day
  3. Plateau pressure <30
  4. Higher PEEP/FiO2 if mod-sev
    Targets
  5. pH 7.25-7.35
  6. PaO2 55-80
  7. O2 sat 88-95%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Pros and Cons of PEEP

A 
Pros
1. Alveolar recruitment
2. Decrease strain on lungs
3. Decrease atelectrauma
Cons
1. Alveolar overdistension
2. Intrapulmonary shunt
3. Increased dead space
4. High pulmonary vascular resistance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

ARDS with high FiO2

A

Should use a higher PEEP strategy!

If FiO2 >50%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Mortality benefit in ARDS

A 
Reduce mortality
- High PEEP
- Prone positioning
Equivocal
- Recruitment maneuvers (not routine)
- NM blockade (consider if PF<150, vent dyssynchrony or difficult lung protection)
- ECMO
- Diuresis/IVF
Increased mortality
- High Hz oscillation
No benefit
- Statins, inhaled NO (bridge, improves oxygenation), steroids
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

General COVID Recommendations

A
  • AGMP = wear N95, negative pressure room
  • Most experienced person intubates
  • Use NE>epi>dop
  • no hydroxyethyl starches - use crystalloids
  • Dex 6 mg IV daily x 10 days
  • No interferon, convalescent plasma, HCQ
  • Remdesevir controversial
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

COVID Ventilation Recommendations

A
  • Suggest O2 <92%, recommend <90%
  • Target no >96%
  • If NIPPV/HFNC monitor closely for deterioration and need for intubation
  • Plat pressure <30
  • Higher PEEP strategy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

COVID O2 Algorithm

A
  • PF >150 = facemask
  • PF <150 = intubate
  • TV 6, PEEP 10, RR 15, FiO2 1
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Weaning from MV

A

Consider if:

  1. Reversed underlying cause
  2. Cardiac stable
  3. Adequate mentation
  4. Oxygenation - FiO2<40, PEEP 5-8, PaO2>60
  5. Other: lyes, A-B, pain control
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Spontaneous Breathing Trial

A
  • Attempt to mimic them breathing on their own
  • ETT inc resistance = harder than breathing on own
  • Should do SBT on pressure support for shorter period of time instead of t piece for longer
  • Ex. PS 5/0
  • Can estimate RSBI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

RSBI

A

Rapid shallow breathing index
= RR/Tidal Volume
RSBI>105 = failed extubation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

RASS

A 
Target RASS -2 to +1
\+4 = combative, violent dangerous
\+3 = pull/remove tubes/cath, aggressive
\+2 = frequent non purposeful movement
\+1 = anxious, apprehensive
0 = alert and calm
-1 = awaken to voice, eyes >10 s
-2 = lid sedation, brief <10 s
-3 = mod sedation, move/open eyes
-4 = deep sedation, no response to voice, respond to physical stimulus
-5 = unrousable, no response
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

ICU Sedation Options

A
  • Prefer propofol or Precedex > benzos
  • Daily awakening trial
  • Stop infusion ASAP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

ICU Delirium

A

Non Pharm
- Sleep, mobilize, hearing/vision aids, orient, daylight, family
Pharm
- Nothing shortens course
- Atypicals preferred ex. quetiapine
- Consider Precedex if preventing weaning/assess extubation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

ICU Pain management

A
  • Multimodal
  • Tylenol and NSAID
  • Opioids esp post op
  • Low dose ketamine and lidocaine = adjuncts
  • Neuropathic = gabapentin, carbamazepine, pregabalin
  • Regional anesthesia- epidural, nerve blocks
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

ICU Sleep

A

Non Pharm

  • Ear plugs, eyeshade, relaxing music, schedule, light/dark
  • NO PROPOFOL
  • Unclear Precedex/melatonin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Post arrest TTM

A
  • Any rhythm
  • In or out of hospital arrest
  • Target Temp 33-36 (or 32-34) –> upper limit if arrhythmia or CV unstable
  • Minimum 24 hours, longer if need to prevent fever
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Brain death

A

Irreversible cessation of cerebral and brainstem function

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Persistent vegetative state

A

Severe anoxic brain injury progressing to a state of wakefulness without awareness
No purposeful response
Sleep wake intact

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Minimal conscious state

A

Limited interaction with environment with visual tracking +/- simple commands
Intelligible verbalization or something yes/no but not always appropriate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Locked In

A

Retained alertness, cognitive abilities, can move eyes and blink voluntarily but paralysis of limbs and oral structures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Neurologic Determination of Death

A
  1. 2 physicians
  2. Etiology compatible with NDD
  3. No confounding factors: umresuscitated shock, T<34, sev metabolic, NM block, peripheral neuropathy/myopathy, drug interactions **if you can’t correct these then use ancillary testing
  4. Absent brain stem reflexes - pupillary, corneal, gag, cough, oculovestibular (cold calorics - towards cold)
  5. Absent movement - spont + noxious (bilateral AND above/below clavicles). EXCLUDES spinal reflexes
  6. Apnea testing
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Apnea testing

A
  1. Correct confounders
  2. Pre oxygenate and get ABG (want CO2 35-45, pH 7.35-7.45)
  3. Disconnect vent
  4. Monitor resp efforts
  5. Serial ABGs
    Complete when:
  6. CO2>60
  7. CO2 >20 above baseline
  8. pH <=7.28
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

NDD Post cardiac arrest

A

Must wait AT LEAST 24 hours before NDD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

NDD Confounding Factors

A
  • May over rule by 2 physicians
  • Therapeutic anti epileptics don’t count
  • Lab recommendations: pH 7.35-7.45, Na 125-159, phos >0.4, Gluc 3-20
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

Ancillary testing

A 
Want to demonstrate absent cerebral flow. Use this if can't fix confounders.
1. Radionuclide angiography
2. CT angiography
3. 4 vessel angiography
4. MR angiography
NOT EEG!!
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

Donation after Cardiocirculatory death

A

Controlled death

  • Withdrawal life support (consent, routine EOL care)
  • 2 physicians confirm death (not from transplant team)
  • Min 5 mins observed with NO pulse, BP, Respiratory effort
  • Can happen in ICU or OR
  • Maximum time is 1-2 hours
66
Q

Critical illness myopathy

A 
Motor
- Flaccid quadriparxsis
- Proximal>distal
- Failure to wean
- Normal CN
- Weak facial muscles
Sensory
- Spared
Reflex
- Normal or low
Other
- CK may be up
- Associated with steroids
- Dx with NCS/EMG
- No treatment
67
Q

Critical illness polyneuropathy

A 
Motor
- Flaccid quadriparesis
- Distal>proximal
- Failure to wean
- Normal CN
Sensory
- Dec pin prick/touch in distal
Reflexes
- Low
Other
- Sev sepsis risk factor
68
Q

Steroid Induced Myopathy

A 
Motor
- 1-3 mos after starting steroids
- Proximal lower>upper limb
- Muscle atrophy
Sensory and Reflexes
- Normal
Other
- Cushing's like syndrome - DM, mood, skin, OP
- Tx - dec steroid dose and improves
69
Q

Risk Factors for critical illness neuropathy/myopathy

A

25% pts vented for at least 7 days
COPD/asthma, liver tx, ARDS, steroid use
Hyperglycemic, hyperthyroid

70
Q

Osmolar gap calculation

A

Serum Osm - Calc Osm

Calc Osm = 2Na + gluc + BUN + 1.25ETOH

71
Q

Sympathetic toxidrome

A

Vitals

  • BP, HR, Temp HIGH
  • RR normal

Eyes = mydriasis (dilated)
Skin = sweat
Mental status = agitated

Ex. cocaine

72
Q

Anticholinergic toxidrome

A 
Vitals
- BP, HR, Temp HIGH
- RR normal
Eyes = mydriasis (dilated)
Skin = dry/hot
Mental status = agitated/mad
Ex. Gravol
73
Q

Cholinergic toxidrome

A 
Vitals
- BP, HR, Temp LOW
- RR HIGH (low sats)
Eyes = miosis (constricted)
Skin = wet/cool
Mental status = N/A
Ex. organophosphates
74
Q

Opioid toxidrome

A 
Vitals
- BP, HR, RR, temp LOW
Eyes = pinpoint (constricted)
Skin = N/A
Mental status = dec LOC
Ex. fentanyl
75
Q

TCA Overdose Symptoms

A
  • TCA is an anticholinergic
  • CVS: HOTN, arrhythmia (sinus tachy, wide QRS –> VT/VF)
  • CNS: dec LOC, agitation, psychosis, delirium, seizures
76
Q

TCA OD Labs

A
  • Serum levels NOT helpful
  • Can detect on URINE tox
  • False positive if quetiapine, Benadryl or cyclobenzaprine
  • Respiratory acidosis
  • ECG
77
Q

TCA ECG

A
  • Wide QRS >100
  • Tall R in AVR
  • Deep slurred S in 1 and AVL
  • Type 1 Brugada - RBBB, downsloping STD in V1-V3
78
Q

TCA OD Treatment

A
  • ABC, MOIF, Poison Control
  • Decontamination - activated charcoal if >2 hrs (slowed gastric emptying) unless dec LOC, perforation or bowel obstruction
  • No inc elimination
  • No antidote
  • May need to tx ALOC/seizures, QTc/arrhythmia
79
Q

TCA LOC management

A
  • GCS 8 intubate
  • Seizures:
    a. Ativan/diazepam
    b. Midazolam infusion
    c. Propofol infusion
    d. Barbiturates

NO PHENYTOIN - cardiac tox

80
Q

TCA HOTN

A

NS or sodium bicarb up to 30 cc/kg

NE if refractory

81
Q

TCA WCT Tx

A
  1. Bicarb 1-2 cc/kg IV –> if QRS narrows start infusion at 250 cc/hr (3 amp in 1L D5)
  2. MgSO4
  3. Lidocaine 1.5 mg/kg bolus then infusion 1-4 mg/min
  4. Lipid emulsion
  5. VA ECMO (not VV)
82
Q

TCA Sodium Bicarb Indications

A
  1. QRS>100, target <120
  2. Ventricular arrhythmia
  3. HOTN
    pH target 7.5-7.55
    Bolus 1-2 amps then infusion 250 cc/hr
83
Q

Ethylene Glycol

A
  • Antifreeze, wiper fluid, cleaners, fuels, moonshine
  • Dec LOC
  • Flank pain, oliguria, hematuria
  • HypoCa
  • CN palsy
    Inv
  • High AG and OG
  • QTc from hypoCa
84
Q

Methanol

A
  • Antifreeze, piper fluid, cleaners, fuels, moonshine
  • Dec LOC
  • Retinal injury = blind
  • RAPD, mydriasis, retinal sheen, hyperaemia optic disc
  • High AG and OG
85
Q

High AG, no OG

A
  • DKA/starvation ketosis
  • Lactic acidosis
  • Tylenol
  • Salicylates
  • Late toxic alcohol
86
Q

High AG, high OG

A
  • Methanol
  • Ethylene glycol
  • Propylene glycol
  • ETOH/DKA
  • ESRD no IHD
87
Q

No AG, high OG

A
  • Isopropyl alcohol
  • Ethanol
  • Sev hyperparaproteinemia/hyperlipidemia
  • Early toxic alcohol
88
Q

Toxic alcohol tx

A
  • ABC, MOIF
  • Decontaminate - no role (maybe NG asp if 60 mins)
  • No treatment
  • Enhanced elimination (methanol) - bicarb bolus then infusion, target pH 7.35
  • ADH
  • HD
  • Folic acid 50 mg q4hr
89
Q

Toxic alcohol tx inhibition

A
  • Inhibit ADH - fomepizole or ethanol
    Indications
  • Methanol >6.2 or Ethylene glycol >3.2
  • Recent hx ingestion of toxic amounts of either with OG>10
  • Suspect ingestion and 2 of: pH <7.3, bicarb <20, OG>10, urine oxalate crystals
90
Q

Toxic alcohol HD

A
  • Definitive therapy
  • Indications:
    1. High AG metabolic acidosis
    2. End organ damage (eye) or renal failure
91
Q

Ethanol level

A

Intoxication 4-10

Account in OG calculation

92
Q

Isopropyl alcohol tx

A

Supportive

93
Q

ASA toxicity Early

A
  • Tinnitus
  • N/V
  • Hyperventilation
  • Fever
94
Q

ASA toxicity late

A
  • Coma/seizures (from cerebral edema)
  • Non cardiogenic pulmonary edema
  • Arrhythmia
  • Thrombocytopenia
  • AKI
95
Q

ASA toxicity glucose

A

Discordance between serum and CSF glucose concentrations
Can have NORMAL serum with LOW CSF
Give 1 amp D50W
Usually once ASA>3

96
Q

ASA tox labs

A
  • Toxic serum level >2.9-3.6
  • Check q2-4 hr
  • Respiratory alkalosis PLUS AGMA
  • If you see resp acidosis think: acute lung injury, CNS depression, mixed overdose (Benzos, alcohol)
97
Q

ASA Overdose Tx - Decontamination

A
  • Activated charcoal 1 g/kg up to 50 g via PO/NG
  • Given within 2 hours - can be longer if enteric coated ASA
  • Consider whole bowel irrigation
  • +/- intubation
98
Q

ASA Overdose Tx - Enhanced elimination

A
  • Alkalinize urine/blood
  • Targets: blood pH 7.4-7.5 and urine 7.5-8
  • Bicarb bolus and infusion 250 cc/hr (watch K, Na, Ca)
  • Correct hypoK first!
99
Q

ASA Overdose Tx - Dialysis

A 
Indications:
LA SHARP
- Liver problem with coagulopathy
- ASA >7.2 acute (>3 chronic)
- Sev A-B/lytes
- Hypoxemia
- ALOC
- Renal failure (with level >6.5)
- Progressive deterioration of vitals
100
Q

Serotonin Syndrome

Symptoms and Timing

A
  1. Autonomic: inc HR, inc BP, N/V/D, fever, sweaty
  2. NM: tremor, rigid lower>upper, myoclonus, hyperreflexia, bilateral babinski, ocular clonus
  3. AMS: anxiety, agitated, restless, disoriented
    Onset within 24 hr, off within 24 hr
101
Q

Neuroleptic malignant syndrome

A

FARM
Fever - >38
Autonomic - tachy, labile BP, sweaty, dysrhythmia
Rigidity - lead pipe/cogwheel, NO CLONUS, hyPOreflexia
Mental status - agitated, delirium, catatonia, coma
On days-weeks, off 2 weeks

102
Q

Serotonin Syndrome

Meds

A

Meds: SSRI, TCA, SNRI, NDRI, MAOI, amphetamines, cocaine, MDMA, levodopa, tramadol, meperidine, St. John’s Wart, VPA, triptans, ergot, fentanyl, buspirone

103
Q

Serotonin Syndrome Dx Criteria

A

Hunter Criteria
Take a serotonergic agent and one of:
- Spontaneous clonus
- Ocular clonus
- Inducible clonus + diaphoresis and agitation
- Tremor and hyperreflexia
- Hypertonic + T>38 plus ocular or inducible clonus

104
Q

Serotonin Syndrome Tx

A
  • Stop agent
  • Supportive
  • Sedate with Benzos
  • If fail - cyprohepatadine
105
Q

NMS Meds

A
  • All neuroleptic drugs
  • Quetiapine, clozapine, risperidone, olanzapine
  • Antiemetic - domperidone, metoclopramide, prochlorperazine
106
Q

NMS Tx

A
  1. Stop agent
  2. Supportive
  3. Cooling blankets
  4. Benzos
  5. Dantrolene and bromocriptine
107
Q

Fluid Choices

A
  • Bicarb only for sev AKI/acidosis, pH<7.15

- Albumin is safe but doesn’t affect outcomes much

108
Q

Fluid responsiveness assessment

A
  • CVP very unreliable

- IVC diameter is pretty unreliable

109
Q

Dexmedetomidine

A
  • Central acting adrenergic alpha 2
  • Sedating and calming while maintaining rousal
  • SFx: bradycardia, HOTN
110
Q

ACLS Compression Rate

A

100-120 bpm

111
Q

ACLS Chest compression depth

A

5-6 cm
Allow recoil
Use backboard

112
Q

Defibrillate in shockable rhythm

A

ASAP

113
Q

Interruptions in CPR

A
  • Intubation shouldn’t interrupt

- No more than 10 sec interruption at a time

114
Q

ACLS naloxone

A

Reasonable adjunct to give if suspected opioid associated emergency

115
Q

ACLS local anesthetic toxicity

A

Lipid emulsion can be given or if other drug toxicities

116
Q

Amiodarone/Lidocaine in ACLS

A

Can give if VF/pulseless VT not responding to defibrillation

117
Q

ACLS Magnesium

A

Not recommended routinely unless torsades

118
Q

ACLS beta blocker

A

No evidence to use early

119
Q

ACLS Lidocaine

A

No evidence to use within 1st hour after ROSC

120
Q

ACLS pregnant

A

Manual left uterine displacement
Prioritize airway management
No fetal monitoring
TTM after (monitor fetus)

121
Q

Pregnant VT with pulse, stable

A

Cardioversion: electric, anti arrhythmic, overdrive pacing
Non long QT monomorphic: sotolol or procainamide
Long QT: beta blocker

122
Q

Pregnant VT with pulse, unstable

A

Cardioversion - synch, safe, may cause fetal arrhythmia

If refractory use amiodarone (non QT long, monomorphic), lidocaine if prolonged

123
Q

Pregnant VT/VF no pulse

A

Defibrillate if appropriate
Move uterus off IVC once 20+weeks
Consider PMCD in later half pregnancy and at 4 mins resusc

124
Q

ACLS Advanced airways

A
  • BMV or advanced airway
  • Supraglottic/LMA - OHCA
  • SGA/ETT OHCA high success rate ETT
  • SGA/ETT in hospital
125
Q

ACLS Vasopressors

A

Epi 1 mg q3-5 min if cardiac arrest
ASAP if non shockable
After initial defibrillates attempts if shockable
Can consider vaso but no advantage

126
Q

ACLS Extracorporeal CPR

A

Not enough evidence for routine

Select patients if rescue

127
Q

ACLS Monitor CPR

A

May use arterial BP or ETCO2 if feasible to monitor quality

128
Q

ACLS Double sequential defibrillation

A

Not supported for refractory shockable rhythm

129
Q

ACLS IV access

A

Try for IV before iO

130
Q

Neuroprognostication - poor neuro outcome findings

A
  1. No N2O somatosensory evoked potential cortical wave 24-72 hrs after arrest/rewarming
  2. Motor M1/M2 at 72 hours
  3. Persistent absence of EEG to external stimuli at 72 hrs
  4. Presence of status myoclonus during first 72 hrs
  5. Absent pupillary light reflex 72 hours+
131
Q

Desaturation in Vented Patient

A
  1. Check connections
  2. Disconnect ETT from vent -and bag ventilate to check for resistance
    a. Airway - blocked tube, bronchoconstriction, auto PEEP
    b. Airspace - blood, pus, water, cells, protein
    c. Pleura - PTX, hemothorax, effusion
    d. Vascular - PE
  3. Deep suction
  4. Ausculate - check trachea midline
  5. Check other vitals
  6. CXR
  7. Hx - new line? new blood?
132
Q

Tracheal assessment - ETT migrated

A

Often to R mainstem bronchus

  • Trachea to LEFT
  • Air entry decrease on LEFT
  • Percussion dec on LEFT
133
Q

Tracheal assessment - PTX

A
  • Trachea away from affected lung
  • Air entry decreased on affected side
  • Percussion inc on affected side
  • May have SC emphysema
134
Q

Tracheal assessment - Collapse

A
  • Trachea towards affected side
  • Air entry decreased affected side
  • Percussion decreased affected side
135
Q

Ventilator Issues - hypoxia and hypercapnea management

A
  1. Hypoxia - inc FiO2, inc PEEP, inc sedation and paralyze, proning, ECMO
  2. Hypercapnia - inc RR, inc tidal volume, inc I:E ratio
136
Q

Assessing intubation difficulty

A
  1. Grade 3 upper lip bite test
  2. Combo findings
  3. Short hyomental distance (<3-5.5 cm)
  4. Retrognathia (mandible <9 cm from angle jaw to tip chin)
  5. Mallampati score 3+
137
Q

Hypothermia rewarming stage I

A 
32-35 Conscious, shivering
Tx
- Warm environment, clothing
- Active movement
- Warm drinks
138
Q

Hypothermia rewarming stage II

A

28-32 Impaired LOC, not shivering
Tx
- Cardiac monitor
- Minimal movements, horizontal, immobile
- Full body insulation
- Active EXTERNAL (heating pack, blankets)
- Minimally invasive rewarming (warmed IVF)

139
Q

Hypothermia rewarming stage III

A

24-28 Unconscious, not shivering, vital signs present

  • Stage II plus airway PRN
  • ECMO if unstable
140
Q

Hypothermia rewarming stage IV

A

<24 - no vitals

II and III plus CPR, up to 3 doses of epi (IV or IO) and defib

141
Q

Acute liver failure management in the ICU

A
  1. No hydroxyethyl starch for initial fluid
  2. NE first line vasopressor
  3. Viscoelastic testing >INR/plts/fibrinogen
  4. No eltrombopag if TCP before surgery/procedure
  5. Vasopressors if HRS
  6. Target glucoses 110-180
142
Q

ECG Long QT

A

“ANTIS”

  • Antipsychotics
  • Antiemetics
  • Antibiotics
  • Antidepressants (TCA)
  • Antiarrhythmics
  • Electrolytes (hypo)
  • Cocaine
143
Q

ECG TCA Toxicity

A
  1. Tall R in AVR
  2. Deep slurred S in I/AVL
  3. Type 1 Brugada - RBBB with downsloping STD V1-3
  4. QRS >100
  5. Tachycardia
144
Q

Digoxin toxicity ECG findings and sx

A

ECG
1. Tachy (VT/VF) or Brady (2/3 degree HB) arrhythmias
2. Accelerated junctional tachycardia
DON’T give Ca for hyperK

Sx

  • N/V
  • Vision blurry
  • Anorexia

Antidote

  • Digibind
  • Use if arrhythmia not respond to therapy, K>5, end organ dysfunction
145
Q

Dilated pupils

A
  • Anticholinergic
  • Sympathetic - cocaine, amphetamines, hallucinogens
  • TCA
  • Methanol
  • Opioid withdrawal
146
Q

Constricted Pupils

A
  • Cholinergic

- Opioids (pinpoint)

147
Q

Normal pupils

A
  • Hypothermia
  • Barbiturates
  • Antipsychotics
148
Q

Tylenol Toxicity

A

Antedote = NAC

- Liver tx if failure = INR up, pH down, hypoglycaemia, encephalitis

149
Q

ASA Toxicity

A

Acute: tinnitus, N/V, hyperventilation, fever
Long: coma/seizures, ALOC, non cardiogenic pulmonary edema, TCP, AKI

Tx: Bicarb to alkalinize urine and blood, HD (>7.2 acute, >3 chronic)

150
Q

Toxic alcohols summary

A

Methanol (visual), ethylene glycol (kidneys, oxalate urine crystals)
Tx: ethanol, fomepizole

151
Q

Carbon monoxide poisoning

A
  • Fires
  • Normal finger O2 and PaO2 but SAT on ABG low
  • Baseline 3% carboxyHb level in non smokers, 10-15% smokers
    Tx
    1. 100% FiO2
    2. Hyperbaric if: CO-Hb >25%, or 20% if pregnant, fetal distress, pH <7.1, MI, LOC
    3. Intubate if comatose
    4. Tx for cyanide poisoning as well if smoke inhalation
152
Q

Cyanide poisoning

A
  • Smoke inhalation, nitroprusside admin
  • ABG = metabolic acidosis (lactate >8), arterial and venous O2 sats equal
  • High CN level >2.4 resp dep and coma, >3 = death
    Tx
    1. 100% FiO2 and ETT
    2. Cyanokit - hydroxycobalamin
    3. Amyl nitrite, sodium nitrite, sodium thiosulfate
    4. Methylene blue high doses (old, less effective)
    NO DIALYSIS
153
Q

Organophosphate antidote

A

Atropine

154
Q

Opioid antidote

A

Naloxone

- Short t1/2 = use drip

155
Q

Benzo antidote

A

Flumazenil

LOWERS seizure threshold

156
Q

BB/CCB antidote

A

Glucagon

High dose insulin (infusion with dextrose)

157
Q

GHB tx

A

supportive care

158
Q

INH antidote

A

Vit B6

159
Q

Lithium overdose

A 
Therapeutic 0.6-1.2
Sx
- N/V/D
- Inc WBC
- CNS sx late
- ECG - ST waves flat in precordial, QTc prolong, brady
Tx
1. Decontamination - can try WBI (SR, sx, unknown amount, <6 hr, >40 mg/kg)
2. IHD if:
- Arrhythmia
- Seizures/AMS
- Serum 5+
- Serum 4+ if Cr >176
3. IVF
160
Q

Organophosphate poisoning symptoms

A
  • Insecticides
  • Reversing NM
  • Tx MG
  • Alzheimers

Muscarinic - DUMBELS

  • Diaphoresis, diarrhea
  • Urination
  • Miotic pupils
  • Bronchospasm, bronchorrhea, bradycardia
  • Emesis
  • Lacrimation
  • Salivation

Nicotinic - MATCH

  • Muscle weakness
  • Adrenergic stimulation - mydriasis
  • Tachycardia
  • CNS
  • HTN
161
Q

Organophosphate delayed neuropathy

A

1-3 weeks after ingestion
Stocking and glove parenthesis
Painful
Then get symmetrical motor polyneuropathy - flaccid weakness of lower extremities

162
Q

Organophosphate poisoning tx

A
  1. 100% FiO2, intubate
  2. IVF if HOTN
  3. Well vented area
  4. Atropine if miosis, sweating, HOTN, resp distress, bradycardia

RCE 2021 (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions