ICU and toxicology (5-10%) complete Flashcards
Central Venous Gas (ScvO2):
- Normal O2 fraction: ______ %
- Septic shock: _____________ % due to ________
- Cardiogenic shock:________%
- Normal O2 fraction: 60-65 %
- > 80% corresponds with high flow states (eg. sepsis). Mitochondrial dysfunction leads to reduced O2 utilization
- < 65% indicates poor forward flow: cardiogenic shock
Sepsis:
Use combo of __________, __________ & __________ to diagnose Sepsis
Use combo of screening tool, lactate & your clinical acumen to diagnose Sepsis
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
• 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
Septic Shock and Steroids:
Dosage: ______________ q ___h
Initiate typically for __________
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)
Sepsis and Oxygen:
Target _____%
Sat _____% increases mortality in critically ill
Target 94-96%,
Sat > 96% increases mortality in critically ill
Contraindications to NIPPV:
- ____________________________
- ____________________________
- ____________________________
- ____________________________
- ____________________________
- ____________________________
• 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)
Ventilator Hacks: How to decrease PaCO2
- _______________________
- _______________________
Ventilator Hacks: How to increase SpO2 (PaO2)
- _______________________
- _______________________
- _______________________
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)
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 ________
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
ARDS Additional Treatment Modalities
Prone positioning:
Mortality benefit if P/F _______, logistically challenging, recommended in experienced centers (PROSEVA trial)
Prone positioning:
Mortality benefit if P/F < 150, logistically challenging, recommended in experienced centers (PROSEVA trial)
Covid-19 Therapies in Critically Ill Patients
Extubation
Assess readiness for extubation:
Sedation
________ or ________are preferable to benzodiazepines
– Reduced _____, ________, ________
– Beware of ________ and ________
Propofol or dexmedetomidine are preferable to benzodiazepines
– Reduced LOS, duration of IMV, delirium
– Beware of bradycardia and hypotension
“modifiable” risk factors for Delirium
- benzodiazepine use and blood transfusions
Post-Arrest Targeted Temperature Management
- Actively prevent _____ (T < _____ deg. C) with ______ and ______ set to ______ deg. C.
- Actively prevent ______ for at least ______ hours.
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.
Neuroprognostication
Neuroprognostication
Clinical Findings Associated with Poor Neurologic Outcome with the highest LR ratio
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.
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.
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 = _____
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
Management of Neurological Injuries
• Preferentially use _____ for fluid management to avoid _____ and avoid _____
Management of Neurological Injuries
• Preferentially use normal saline for fluid management to avoid significant sodium shifts and avoid hyponatremia
Critical Illness Associated Weakness
- Critical illness myopathy
- Critical illness polyneuropathy
- Glucocorticoid-induced myopathy
How to differentiate?
- Motor?
- Sensory?
- Reflex?
- Others?
TCA Overdose:
Labs
• ______ levels are not helpful
– Urine tox can detect TCA use, but beware of false positives (______, ______, ______, ______)
TCA Overdose:
Labs
• TCA serum levels are not helpful
– Urine tox can detect TCA use, but beware of false positives (carbamazepine, diphenhydramine, cyclobenzaprine, quetiapine)
ECG changes with TCA poisoning:
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 –> __________, __________
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
Toxic Alcohols
Toxic Alcohols
Seizure management in Toxicology
• Start with ____ or _____, add ______ if refractory
• Then ______ if refractory
• Then ______
• DO NOT USE ______ -> Why?
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
Treatment of Toxic Alcohols:
Enhanced elimination
- Give _________
- Goal pH= _____
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
Treatment of Toxic Alcohols:
_________ or _________ with:
• _________ for methanol
• _________ and _________ for ethylene glycole
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
Treatment of Toxic Alcohols:
Indication for HemoDialysis?
Treatment of Isopropyl Alcohol poisoning:
Supportive
Salicylate Toxicity
Salicylate Toxicity and Glucose?
What if serum glucose is normal?
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%
Salicylate toxicity:
Labs
• Salicylate level
– Toxicity with serum levels greater than ______mmol/L
– Order levels q _____ hours
• ABG/VBG
______________________________
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
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
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
Salicylate toxicity:
Treatment: Enhanced Elimination
• Dialysis indicated if patient has one of the following?
- ___________________________________________
- ___________________________________________
- ___________________________________________
- ___________________________________________
- ___________________________________________
- ___________________________________________
- ___________________________________________
- ___________________________________________
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
NAC infusion in Acetaminophen toxicity: whether to stop the infusion or not in the following circumstances:
- Anaphylaxis
- Angioedema or respiratory symptoms
- Flushing
- Urticaria
NAC Adverse Reactions
- Anaphylaxis
• Stop infusion
• Treat for anaphylaxis as below
• Do NOT restart - Angioedema or respiratory symptoms
• Monitor for airway compromise
• Diphenhydramine, Salbutamol
• Epinephrine, Methylprednisolone
• Stop infusion – can restart 1h after epi if
reaction resolves - Flushing
• Continue infusion - Urticaria
• Stop infusion
• IM epi + diphenhydramine + steroid
• Restart infusion when resolves
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 ______________
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
Tracheal displacement in different scenarios:
- ETT migrated (commonly to R
mainstem bronchus) - Pneumothorax
- Collapse (mucous plug)
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).
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).
Serotonin syndrome vs NMS
Serotonin syndrome vs NMS (continued)
Hypothermia?
Lithium Overdose
