ICU + Toxicology Flashcards

Question

Indications for high flow nasal canula

Answer 1

Hypoxemic respiratory failure Patients taking NIV breaks Post-op patients

Answer 2

Post extubation if high risk of failure (NIV preferred) Acute hypercapnic respiratory failure

Answer 3

reduced respiratory muscle oxygen consumption recruitment of alveoli improved V/Q matching Reduced LV afterload Reduced preload

Answer 4

reduced respiratory muscle oxygen consumption recruitment of alveoli improved V/Q matching Reduced LV afterload Reduced preload Increased Alveolar ventilation

Answer 5

BiPAP mild-severe acidosis (rr >20-24, pH<7.35, PaCO2>45) Cardiogenic pulmonary edema

Answer 6

treatment of post-extubation resp failure Hypercapnic with NO acidosis No recommendations for: Asthma Resp Failure NYD, Acute resp failure secondary to viral illness.

Answer 7

Facial surgery, trauma, airway obstruction Decreased LOC (includes worsening agitation when starting BiPAP) Inability to clear secretions Respiratory arrest Hemodynamic instability (reduces preload) Strong indications for intubation.

Answer 8

increase RR Increase Tidal volume (minute ventilation = RR*Tidal volume)

Answer 9

increase FiO2 increase PEEP Increase Inspiratory time Affect O2 Delivery: Inc. CO, Inc Hb Dec. O2 consumption: treat fever, agitation stop pulmonary vasodilators (nitroprusside)

Answer 10

reflects airway resistance + Lung compliance Target <35cm H2O

Answer 11

The pressure in the lungs when no air is moving, reflects lung compliance This is the pressure that the alveoli are seeing target <30cm H20 May be confounded by chest wall restriction (IE Obesity)

Answer 12

Pressure at the end of the respiratory cycle Increases solubility of gas Splits airways, decreases work of breathing.

Answer 13

Pplat - PEEP (Target <15) OR Tidal Volume/ Static compliance

Answer 14

IVIG Vitamin C Polymyxin Angiotensin II infusion Levosimendan Activated Protein C Liberal oxygen (target 94-96%, a sat >96% increases mortality in critically ill)

Answer 15

Timing: within 1 week of known insult Pulmonary edema that is not attributable to Cardiogenic or fluid overload Bilateral infiltrates on CXR, CT or Ultrasound (by a trained professional) *P:F 201-300 with NIV/CPAP PEEP ≧ 5 or HFNC >30l/min SpO2:FiO2 <315 with SpO2 <97%

Answer 16

Timing: within 1 week of known insult Pulmonary edema that is not attributable to Cardiogenic or fluid overload Bilateral infiltrates on CXR, CT or Ultrasound (by a trained professional) *P:F 101-200 with NIV/CPAP PEEP ≧ 5 or HFNC >30l/min SpO2:FiO2 <315 with SpO2 <97%

Answer 17

Timing: within 1 week of known insult Pulmonary edema that is not attributable to Cardiogenic or fluid overload Bilateral infiltrates on CXR, CT or Ultrasound (by a trained professional) *P:F <100 with NIV/CPAP PEEP ≧ 5 or HFNC >30l/min SpO2:FiO2 <315 with SpO2 <97%

Answer 18

1. ventilation strategies 2. Prone position 3. Neuromuscular blockade 4. ECLS/ECMO 5. Corticosteroids 6. Inhaled pulmonary vasodilator

Answer 19

* Proteinaceous fluid fills alveoli * Neutrophils flood alveolar space * Hyaline membranes form on epithelial basement membrane * Microthrombi form * Fibrosis develops (late stage)

Answer 20

Direct Lung Injury * Pneumonia * Aspiration pneumonitis * Drowning * Thoracic trauma/pulmonary contusion * Smoke or toxic inhalation * Fat emboli * Reperfusion injury (post lung transplant) Systemic inflammation * Severe sepsis * Transfusion reaction (TRALI) * Shock * Pancreatitis

Answer 21

Mode: Volume Control Tidal volume (Vt): Initial Vt at 6ml/kg PBW à target 4-8 ml/kg PBW Plateau pressure: ≤ 30 cm H2O, Driving pressure (Pplat - PEEP) target < 15 cm H2O PEEP: target higher PEEP in mod/severe ARDS, based on FiO2-PEEP Tables SpO2: target 88-93% or PaO2 55 - 80 mmHg (avoid hyperoxia – ↑s harm) CO2: permissive hypercapnia allowed, target pH > 7.25 * Deep sedation to achieve the above parameters * Lung Recruitment Maneuvers: Don’t use routinely (evidence of ↑ mortality). Can be considered. * High frequency oscillation: Do not use

Answer 22

* Severe ARDS * Hypercapneic respiratory failure * Bridge to lung transplantation * Primary graft dysfunction after lung transplantation * Status asthmaticus

Answer 23

Absolute * Disseminated malignancy * Known severe brain injury * Prolonged CPR without adequate tissue perfusion * Severe chronic organ dysfunction * Severe chronic pulmonary hypertension * Non-recoverable advanced comorbidity (ie. CNS damage or terminal malignancy)

Answer 24

Call for ECMO referral if: * P/F < 80 mmHg for > 6 hours OR P/F < 50 mmHg for > 3 hours * PaCO2 > 60 mmHg for > 6 hours (despite optimization of vent) * Mechanically ventilated < 7 days * BMI < 40 or weight < 125 kg * Age 18 - 65

Answer 25

Should occur daily

Answer 26

Assess readiness for weaning from ventilator 1. Reversal of underlying reason for intubation and ventilation 2. Improvement of oxygenation (PaO2 > 60 mmHg, FiO2 < 40%, PEEP < 8) 3.Ability to perform work of breathing (Normal/compensated Co2, pH, adequate cardiac function, adequate diaphragm function)

Answer 27

Assess readiness for extubation 1. Adequate cough 2. Minimal secretions, ability to manage secretions 3. Awake/Alert, following commands, no sedation 4. No increased risk of airway obstruction – post-op swelling resolved, ETT cuff leak present

Answer 28

* Alpha-2 agonist – acts on CNS receptors * Recent meta-analysis compared to Propofol and Benzodiazepines: – ↓risk of delirium (RR 0.67, 95% CI 0.55 to 0.81; moderate certainty) – ↓ duration of mechanical ventilation (MD - 1.8 h, 95% CI - 2.89 to - 0.71; low certainty) – ↓ ICU length of stay (MD - 0.32 days, 95% CI - 0.42 to - 0.22; low certainty) – Increased risk of bradycardia (RR 2.39, 95% CI 1.82 to 3.13; moderate certainty) and hypotension (RR 1.32, 95% CI 1.07 to 1.63; low certainty)

Answer 29

Haloperidol and Queiapine first line for delirium when at risk of hurting someone

Answer 30

Multimodal approach to pain management * Opioids are mainstay, especially post-op, but associated with side effects (respiratory depression, delirium, dependence) * Adjuncts should be used to reduce opioid requirements – Acetaminophen, NSAIDS (where appropriate) – Low dose ketamine (0.5 mg mg/kg bolus then 1-2 mcg/kg/min infusion) in post-operative patients – Gabapentin, pregabalin, carbamazepine for neuropathic pain – Do not routinely use lidocaine, local anesthetics or inhaled volatiles for pain adjuncts (may be effective for special circumstances – postoperative, trauma) * Others recommended: cold therapy, relaxation techniques, music, massage

Answer 31

neuroprognostication should wait at least 24 hours

Answer 32

3 pre-requisites before conducting DNC assessment 1. Mechanism causing devastating brain injury leading to death 2. Neuroimaging to support cause 3. Absence of confounders – Temperature: core ≥ 36 celsius (rectal, esophageal, bladder, arterial, bladder, central venous) – Time: wait ≥ 48hrs after arrest (unless imaging shows devastating injury) – Drugs: Wait 5 half lives if drug is known (e.g. sedatives, neuromuscular blockers, – Shock: Must be resuscitated appropriately (i.e. not un-resuscitated) – Metabolic disorders*: Na 125-159, PO4 >0.4, Glucose 3-30, pH 7.28-7.5, PaCO2 < 60, Urea < 40 (if available), Cr < 400, bilirubin < 100 “If these derangements cannot be corrected and are judged to be potentially contributing to the loss of brain function, ancillary investigation should be considered. ” – Severe weakness: myasthenia, ALS, spinal cord injury – Decompressive craniectomy

Answer 33

High lactate can be misinterpreted and ethylene glycol so if you see a very high lactate be suspicious of a toxic alcohol

Answer 34

Sodium bicarbonate

Answer 35

High-Dose Euglycemic Insulin, glucagon, calcium, intralipid

Answer 36

Flumazenil [caution – lasts up to an hour and if multiple drug ingestions or withdrawal seizure will make managing seizures a challenge!]

Answer 37

Hydroxycobalamin, sodium thiosulfate,

Answer 38

Deferoxamine

Answer 39

Pyridoxine

Answer 40

Digibind An IgG Anti digoxin antibody. These fragments bind free digoxin, thereby forming digoxin-immune fragment complexes. As the level of free digoxin in plasma falls, the resulting concentration gradient facilitates dissociation of digoxin from the sodium-potassium ATPase. Fab fragment complexes are renally excreted.

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ICU + Toxicology Flashcards

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