ICU and toxicology

Question 1

What is the definition of septic shock?

Answer 1

Lactate > 2

Vasopressors to keep MAP > 65 despite absence of hypovolemia

Question 2

What are targets for septic shock resuscitation?

Answer 2

Early broad spectrum abx
Fluid resus 30ml/Kg (RL > NS unless TBI)
MAP >= 65mmHg
Repeat lactate in 2-4hr if initial > 2

Question 3

What are components of lung protective ventilation?

Answer 3

1. Td Volume 4-8mL/kg (predicted BW)
2. Plateau pressure < 30cm H2)
3. Proning for P:F<100
4. Higher PEEP/FiO2
5. RR increase to keep pH between 7.3-7.35, don’t exceed 35 bpm or pCO2<25.
6. Permissive hypoxia/ hypercarbia (sat 88-95%, pO2 55-80, pH 7.25 - 7.35)
7. I:E ratio if CO2 retaining or breath stacking

Question 4

What are JAMA RCE findings of difficult intubation?

Answer 4

1. Grade 3 upper lip bite test (LR+ 14)
2. Short hyomental dis. (< 3-5.5cm, LR+ 6.4)
3. Retrognathia (LR+ 6.0)
4. Mallampati score >=3 (LR+ 4.1)

Question 5

What are criteria for extubation?

Answer 5

1. Reversal of underlying cause for intubation
2. Stable cardiac status
3. Adequate mentation
4. Adequate oxygenation (PaO2 > 60 on FiO2 < 40% and PEEP 5-8)

Question 6

What is the temperature target for post cardiac arrest management?

Answer 6

33-36 degrees (consider 36 if arrhythmia or instability)

Question 7

How long do you cool after cardiac arrest?

Answer 7

24 hours

Question 8

What is the difference between brain death, persistent vegetative state, minimal concious state and locked in?

Answer 8

Brain death - irreversible cessation of cerebral and brain stem function

Persistent vegetative state - wakeful without awareness, no purposeful response but may have sleep/wake cycle

Minimal concious state - limited interaction with environment

Locked in - retained alertness and cognition, can move eyes/blink voluntarily

Question 9

What confounding factors must be excluded before determining neurological death?

Answer 9

Unresusitated shock
Core temp < 34
Metabolic disorders
Neuromuscular blockade
Peripheral neuropathy/myopathy
Drug intoxications

Question 10

How do you do apnea testing?

Answer 10

Preoxygenate and start with paCO2 35-45, pH 7.35-7.45

Disconnect from vent, serial ABG
Threshold pCO2 > 60 AND > 20 mmHG above baseline AND pH < 7.28

Question 11

How do you differentiate clinically ethylene glycol vs methanol poisoning?

Answer 11

EG: cranial nerve palsies, frank hematuria, hypocalcemia

MtOH (EYE FINDINGS) retinal injury, RAPD, mydriasis, hyperemia of optic disc

Question 12

What are indications for fomepizole in methanol or ethylene glycol overdose?

Answer 12

Methanol > 6.2
Ethylene glycol > 3.2
Documented ingestion with osmolar gap > 10
Suspicion of overdose with 2 of the following:
- pH < 7.3
- Bicarb < 20
- Osmolar gap > 10
- urine oxalate crystals

Question 13

What is the target pH for TCA toxicity when it comes to bicarb infusion?

Answer 13

pH 7.5-7.55

Question 14

How do you treat wide complex tachycardia associated with TCA overdose?

Answer 14

Bicarb infusion. If fails, start Lidocaine. If that fails, start lipid emulsion

Question 15

What are dialysis indications for toxic alcohol ingestions?

Answer 15

High anion gap metabolic acidosis and evidence of end organ damage

Question 16

What are indications for dialysis in ASA toxicity?

Answer 16

Salicylate level > 7.2 (or > 6.5 if AKI)
Hypoxemia requiring O2
Altered LOC
Severe acid/base or lytes disturbances
Hepatic compromise with coagulopathy

Question 17

What do you have to suspect if ASA toxicity and respiratory acidosis?

Answer 17

Acute lung injury
CNS depression
Mixed overdoses

Question 18

What are findings of NMS?

Answer 18

FARM

Fever
Autonomic instability - tachy, labile BP, disarrythmia, diaphoresis
Rigidity - NO CLONUS, HYPOREFLEXIVE
Mental status changes - agitated, coma

Question 19

What are findings of serotonin syndrome?

Answer 19

Autonomic (tachy, hypertensive, fever, diarrhea, diaphoretic)

Neuromuscular HYPERactivity (tremour, rigidity, myoclonus, hyperreflexia)

Mental status changes (agitated, restless, disoriented)

Question 20

What are normal central venous and mixed venous sat? How do we use to differentiate septic vs cardiogenic shock?

Answer 20

Central venous sat 60-65%
Mixed venous sat 65 - 70%

Septic shock sat > 80% (high flow states)
Cardio shock sat < 60% (poor flow)

Question 21

What are indications for hyperbaric O2 in CO poisoning?

Answer 21

CO-Hb > 25% (>20% if preg)
MI
pH < 7.1
Decreased LOC

Question 22

What is the antidote for BB/CCB poisoning?

Answer 22

Glucagon + high dose insulin

Question 23

How do you treat carbon monoxide poisoning?

Answer 23

High flow O2
Remove source of CO
Consider for hyperbaric O2
If smoke inhalation, treat for cyanide toxicity too

Question 24

What is a key blood gas finding of cyanide poisoning?

Answer 24

Decreased AV O2 gradient (venous arterialization)

Question 25

What is the antidote for cyanide toxicity?

Answer 25

Intubate
Hydroxycobalamine
Nitrites/Sodium thiosulfate

Question 26

What is the dialysis indication for lithium?

Answer 26

> = 5mmol or >=4 if Cr > 176