ICU and toxicology (5-10%) complete

Question 1

Central Venous Gas (ScvO2):

1. Normal O2 fraction: ______ %
2. Septic shock: _____________ % due to ________
3. Cardiogenic shock:________%

Answer 1

1. Normal O2 fraction: 60-65 %
2. > 80% corresponds with high flow states (eg. sepsis). Mitochondrial dysfunction leads to reduced O2 utilization
3. < 65% indicates poor forward flow: cardiogenic shock

Question 2

Sepsis:

Use combo of __________, __________ & __________ to diagnose Sepsis

Answer 2

Use combo of screening tool, lactate & your clinical acumen to diagnose Sepsis

Question 3

Predicting Fluid Responsiveness and IVC

• Intubated, fully ventilated: Use _________
_________ > ______ likely to be fluid responsive

• Intubated, breathing spontaneously: _________

• Spontaneously breathing, not intubated:
IVC ____ cm and variation _____ % likely fluid responsive

Answer 3

• Intubated, fully ventilated:
Distensibility Index >15-20% likely to be fluid responsive

• Intubated, breathing spontaneously: cannot use

• Spontaneously breathing, not intubated:
IVC <2cm and variation >50% likely fluid responsive

Question 4

Septic Shock and Steroids:

Dosage: ______________ q ___h

Initiate typically for __________

Answer 4

Typically hydrocortisone 50 mg IV q6h

Initiate typically for refractory shock (Norepinephrine is at ~ 0.2 ug/kg/min, or when you’re adding a second-line vasopressor agent)

Question 5

Sepsis and Oxygen:

Target _____%

Sat _____% increases mortality in critically ill

Answer 5

Target 94-96%,

Sat > 96% increases mortality in critically ill

Question 6

Contraindications to NIPPV:

1. ____________________________
2. ____________________________
3. ____________________________
4. ____________________________
5. ____________________________
6. ____________________________

Answer 6

• Facial surgery, facial trauma, airway obstruction
• Decreased LOC (*relative)
• Inability to clear secretions
• Respiratory arrest
• Hemodynamic instability (reduces preload)
• Indication for intubation (e.g. airway protection)

Question 7

Ventilator Hacks: How to decrease PaCO2
- _______________________
- _______________________

Ventilator Hacks: How to increase SpO2 (PaO2)
- _______________________
- _______________________
- _______________________

Answer 7

Ventilator Hacks: How to decrease PaCO2
- Increase RR
- Increase tidal volume
(minute ventilation = RR * Vt)

Ventilator Hacks: How to increase SpO2 (PaO2)
- Increase FiO2
- Increase PEEP
- Extend inspiratory time

Affect O2 delivery: Increase cardiac output, Increase Hb, decrease O2 consumption: treat fever and agitation. Remove pulm vasodilators (eg nitroprusside)

Question 8

Lung Protective Ventilation in ARDS

• Tidal volume (Vt): Initial Vt at ____ml/kg PBW -> target ____ ml/kg PBW

• Plateau pressure (Pplat): measure with ______, target ____ cm H2O

• Driving pressure (Pplat - PEEP): target ____ cm H2O

• PEEP: target higher PEEP based on FiO2-PEEP Tables (don’t memorize)

• SpO2: target _____% or PaO2 _____ mmHg (avoid ______ – increase in harm)

• CO2: permissive _____ allowed,
target pH ________

Answer 8

Lung Protective Ventilation in ARDS

• Tidal volume (Vt): Initial Vt at 6ml/kg PBW à target 4-8 ml/kg PBW

• Plateau pressure (Pplat): measure with inspiratory pause, target < 30 cm H2O

• Driving pressure (Pplat - PEEP): target < 15 cm H2O

• PEEP: target higher PEEP based on FiO2-PEEP Tables (don’t memorize)

• SpO2: target 88-95% or PaO2 55 - 80 mmHg (avoid hyperoxia – increase in harm)

• CO2: permissive hypercapnia allowed, target pH 7.25 – 7.35

Question 9

ARDS Additional Treatment Modalities

Prone positioning:
Mortality benefit if P/F _______, logistically challenging, recommended in experienced centers (PROSEVA trial)

Answer 9

Prone positioning:
Mortality benefit if P/F < 150, logistically challenging, recommended in experienced centers (PROSEVA trial)

Question 10

Covid-19 Therapies in Critically Ill Patients

Answer 10

Question 11

Extubation
Assess readiness for extubation:

Answer 11

Question 12

Sedation

________ or ________are preferable to benzodiazepines
– Reduced _____, ________, ________
– Beware of ________ and ________

Answer 12

Propofol or dexmedetomidine are preferable to benzodiazepines
– Reduced LOS, duration of IMV, delirium
– Beware of bradycardia and hypotension

Question 13

“modifiable” risk factors for Delirium

Answer 13

• benzodiazepine use and blood transfusions

Question 14

Post-Arrest Targeted Temperature Management

• Actively prevent _____ (T < _____ deg. C) with ______ and ______ set to ______ deg. C.
• Actively prevent ______ for at least ______ hours.

Answer 14

Post-Arrest Targeted Temperature Management

• Actively prevent fever (T < 37.7 deg. C) with antipyretics and cooling blankets set to 37.5 deg. C.
• Actively prevent fever for at least 72 hours.

Question 15

Neuroprognostication

Answer 15

Question 16

Neuroprognostication

Clinical Findings Associated with Poor Neurologic Outcome with the highest LR ratio

Answer 16

Question 17

Neurologic Determination of Death (NDD)

Minimum Clinical Criteria
• At least ____h after cardiac arrest (note AHA says __h)

• ___ Physicians – both ______ licensed

• Established ______: compatible with ______

• Absence of ______

• Absent ______: ______, ______, ______, ______, ______

• Absent ______: ______+ ______ (______; EXCLUDES ______)

• ______ Testing

*If confounding factors cannot be corrected, ______ should be used to establish the diagnosis.

Answer 17

Neurologic Determination of Death (NDD)

Minimum Clinical Criteria
• At least 24h after cardiac arrest (note AHA says 72h)

• 2 Physicians – both independently licensed

• Established etiology: compatible with NDD

• Absence of confounding factors

• Absent brain stem reflexes: pupillary response, corneal, gag, cough, oculovestibular (cold calorics) *don’t have to do doll’s eyes (CI in C-spine injury)

• Absent movement: spontaneous + noxious stimuli (bilaterally AND above/below clavicles; EXCLUDES spinal reflexes)

• Apnea Testing

*If confounding factors cannot be corrected, ancillary testing should be used to establish the diagnosis.

Question 18

NDD: Some Nuances

• Confounding Factors:
– __________ ( _____ degrees C)
– Electrolyte (P04 _____mmol/L, Ca _____mmol/L, Mg _____ mmol/L, Na >_____mmol/L or
< _____mmol/L, Glucose _____ mmol/L)
– _____ blockers
– _____ shock
– _____ dysfunction
– _____ metabolism
– _____
– _____ encephalopathy-Need _____h after cardiac arrest

• Ancillary Testing:
– Goal = _____
– Accepted = _____, _____, _____, _____
– Not Accepted = _____

Answer 18

NDD: Some Nuances

• Confounding Factors:
– Hypothermia (<34 degrees C)
– Electrolyte (P04<0.4mmol/L, Ca<1mmol/L, Mg<0.8mmol/L, Na>160mmol/L or <125mmol/L, Glucose<4mmol/L)
– Neuromuscular blockers
– Un-resuscitated shock (hypotension/hypoperfusion despite fluids+pressors)
– Peripheral nerve or muscle dysfunction (GBS, Botulism, Myasthenia Gravis)
– Inborn errors of metabolism
– Drugs
– Hypoxic ischemic encephalopathy-Need 24h after cardiac arrest

• Ancillary Testing:
– Goal = demonstrate absent cerebral blood flow
– Accepted = radionuclide angiography, CT angiography, traditional 4-vessel angiography, MR angiography
– Not Accepted = EEG

Question 19

Management of Neurological Injuries

• Preferentially use _____ for fluid management to avoid _____ and avoid _____

Answer 19

Management of Neurological Injuries

• Preferentially use normal saline for fluid management to avoid significant sodium shifts and avoid hyponatremia

Question 20

Critical Illness Associated Weakness

1. Critical illness myopathy
2. Critical illness polyneuropathy
3. Glucocorticoid-induced myopathy

How to differentiate?
- Motor?
- Sensory?
- Reflex?
- Others?

Answer 20

Question 21

TCA Overdose:

Labs
• ______ levels are not helpful

– Urine tox can detect TCA use, but beware of false positives (______, ______, ______, ______)

Answer 21

TCA Overdose:

Labs
• TCA serum levels are not helpful

– Urine tox can detect TCA use, but beware of false positives (carbamazepine, diphenhydramine, cyclobenzaprine, quetiapine)

Question 22

ECG changes with TCA poisoning:

Answer 22

Question 23

TCA Overdose:

Treatment of Arrhythmias
• Wide complex (ventricular) tachy OR prolonged QRS > _____

– __________ –> if QRS narrows start __________

– If fails, give __________ (be ready for __________)

– If fails, __________

– If fail and unstable –> __________, __________

Answer 23

TCA Overdose:

Treatment of Arrhythmias
• Wide complex (ventricular) tachy OR prolonged QRS > 100

– Na Bicarb 1-2mEq/kg IV –> if QRS narrows start infusion (3amps in a bag of D5W) at 250ml/h

– If fails, give magnesium sulfate (be ready for hypotension)

– If fails, lidocaine (class IB) 1.5mg/kg bolus then 1-4mg/min
• Class IA, 1C, and III anti-arrhythmic are C/I

– If fail and unstable –> lipid emulsion, VA ECMO

Question 24

Toxic Alcohols

Answer 24

Toxic Alcohols

Question 25

Seizure management in Toxicology

• Start with ____ or _____, add ______ if refractory

• Then ______ if refractory

• Then ______

• DO NOT USE ______ -> Why?

Answer 25

Seizures

• Start with Ativan or diazepam, add midazolam infusion if refractory

• Then propofol infusion if refractory

• Then Barbiturates

• DO NOT USE PHENYTOINv- > Enhances Cardiac Toxicity

Question 26

Treatment of Toxic Alcohols:
Enhanced elimination

• Give _________
• Goal pH= _____

Answer 26

Treatment of Toxic Alcohols:
Enhanced elimination

–Acidemia allows toxic metabolites to penetrate end-organ tissue, so give bicarb!

–Give 1-2meq/kg then set up an infusion at 150 250 cc/h

– The goal pH=7.35

Question 27

Treatment of Toxic Alcohols:

_________ or _________ with:
• _________ for methanol
• _________ and _________ for ethylene glycole

Answer 27

Treatment of Toxic Alcohols:

Fomepizole or ethanol with:
• Folic acid 50 mg IV q6h for methanol
• Thiamine 100 mg IV and pyridoxine 50 mg IV for ethylene glycole

Question 28

Treatment of Toxic Alcohols:
Indication for HemoDialysis?

Answer 28

Question 29

Treatment of Isopropyl Alcohol poisoning:

Answer 29

Supportive

Question 30

Salicylate Toxicity

Answer 30

Question 31

Salicylate Toxicity and Glucose?

What if serum glucose is normal?

Answer 31

Give DEXTROSE even if serum glucose is normal.

• Salicylate toxicity leads to neuronal energy depletion as salicylates uncouple neuronal and glial oxidative phosphorylation
• Lead to discordance between serum and CSF glucose concentrations

–Despite normal serum glucose concentrations, CSF glucose concentrations are low in 33%

Question 32

Salicylate toxicity:
Labs

• Salicylate level
– Toxicity with serum levels greater than ______mmol/L
– Order levels q _____ hours

• ABG/VBG
______________________________

Answer 32

Labs:

• Salicylate level
– Toxicity with serum levels greater than 2.9 3.6mmol/L
– Order levels q 2-4 hours

• ABG/VBG
– Respiratory alkalosis –> direct stimulation of the resp center
– Anion gap metabolic acidosis –> uncoupling of oxidative phosphorylation
– Common to see a mixed acid-base disturbance with 2 primary problems
– If concurrent respiratory acidosis, consider:
– Acute lung injury
– CNS depression
– Mixed overdose

Question 33

Salicylate toxicity:

Enhanced Elimination

• _______ the urine and blood
– Aim to have a blood pH 7.4-7.5, do not go above 7.55 and urine pH 7.5-8
– Give 1-2mEq/kg IV bicarb then start an infusion at 250ml/h
• Watch K, Na and Ca
– Correct hypokalemia before alkalinization
• In hypokalemia, the renal tubules will absorb K and excrete H+, preventing alkalinization

Answer 33

Salicylate toxicity:

Enhanced Elimination

• Alkalinize the urine and blood
– Aim to have a blood pH 7.4-7.5, do not go above 7.55 and urine pH 7.5-8
– Give 1-2mEq/kg IV bicarb then start an infusion at 250ml/h
• Watch K, Na and Ca
– Correct hypokalemia before alkalinization
• In hypokalemia, the renal tubules will absorb K and excrete H+, preventing alkalinization

Question 34

Salicylate toxicity:
Treatment: Enhanced Elimination

• Dialysis indicated if patient has one of the following?
- ___________________________________________
- ___________________________________________
- ___________________________________________
- ___________________________________________
- ___________________________________________
- ___________________________________________
- ___________________________________________
- ___________________________________________

Answer 34

Treatment: Enhanced Elimination
• Dialysis indicated if patient has one of the following:
– Levels >7.2mmol/L
– Hypoxemia requiring supplemental O2
– A change in mental status
– Renal failure (and level >6.5mmol/L)
– Progressive deterioration of vital signs
– Severe acid–base or electrolyte imbalance despite appropriate treatment (pH <7.2)
– Hepatic compromise with coagulopathy
– Volume overload preventing admin of sodium bicarb

Question 35

NAC infusion in Acetaminophen toxicity: whether to stop the infusion or not in the following circumstances:

1. Anaphylaxis
2. Angioedema or respiratory symptoms
3. Flushing
4. Urticaria

Answer 35

NAC Adverse Reactions

1. Anaphylaxis
   • Stop infusion
   • Treat for anaphylaxis as below
   • Do NOT restart
2. Angioedema or respiratory symptoms
   • Monitor for airway compromise
   • Diphenhydramine, Salbutamol
   • Epinephrine, Methylprednisolone
   • Stop infusion – can restart 1h after epi if
   reaction resolves
3. Flushing
   • Continue infusion
4. Urticaria
   • Stop infusion
   • IM epi + diphenhydramine + steroid
   • Restart infusion when resolves

Question 36

Opiate Use Disorder:

Naltrexone:
- Must be OFF opioids _______ to avoid precipitated withdrawal.

Buprenorphine/Naloxone* (SUBOXONE)
IM Buprenorphine (SUBLOCADE) q __ d
- Pt must be in withdrawal ______ opioid free to initiate

Methadone
- Must be OFF opioids ______
- Watch out for ______________

Answer 36

Opiate Use Disorder:

Naltrexone:
Must be OFF opioids 7-10d to avoid precipitated
withdrawal

Buprenorphine/Naloxone* (SUBOXONE)
IM Buprenorphine (SUBLOCADE) q 28 d:
- Pt must be in withdrawal 12-24h opioid free to
initiate

Methadone:
- Can start immediately
- Need special license to prescribe
- QT prolonging

Question 37

Tracheal displacement in different scenarios:

1. ETT migrated (commonly to R
   mainstem bronchus)
2. Pneumothorax
3. Collapse (mucous plug)

Answer 37

Question 38

Management of Liver Failure (CCM 2020 Guidelines)

We recommend ______________ over measuring international normalized ratio (INR), platelet, and fibrinogen, in critically ill patients with ALF or ACLF undergoing procedures (strong recommendation, moderate-quality evidence).

Answer 38

Management of Liver Failure (CCM 2020 Guidelines)

We recommend viscoelastic testing (TEG/ROTEM), over measuring international normalized ratio (INR), platelet, fibrinogen, in critically ill patients with ALF or ACLF undergoing procedures (strong recommendation, moderate-quality evidence).

Question 39

Serotonin syndrome vs NMS

Answer 39

Question 40

Serotonin syndrome vs NMS (continued)

Answer 40

Question 41

Hypothermia?

Answer 41

Question 42

Lithium Overdose

Answer 42