Intensive care cases and concepts

Question 1

if HCO3 changes first

Answer 1

either metabolic acidosis or alkalosis

Question 2

if PCO2 changes first

Answer 2

either respiratory acidosis (elevated PCO2)

or respiratory alkalosis (reduced PCO2)

Question 3

ventilator failure

Answer 3

high CO2

• acute: drug over dose, asthma, stroke
• chronic: emphysema, neuromuscular

Question 4

oxygenations failure

Answer 4

Low O2

• acute: pneumonia, PE
• chronic: emphysema, fibrosis
• polycythemia
• clubbing
• pulmonary HTN

Question 5

airway failure

Answer 5

cannot protect

-alerted mental status, NM weakness

Question 6

NIPPV

Answer 6

CPAP

BiPAP

Question 7

CPAP

Answer 7

continuous positive airway pressure

• pressure applied during inspiration and expiration at the same time
• sleep apnea patients

Question 8

BiPAP

Answer 8

• bilevel positive airway pressure
• gives inspiratory pressure and expiratory
• inspiratory pressure augments patients own tidal volume this improving ventilation (blowing off CO2)

Question 9

contraindications of NIPPV

Answer 9

• altered mental status: no gag reflex
• facial deformity or trauma
• stridor or burns or obstruction of airway
• cardiac or respiratory arrest
• unable to clear sputum
• recent thoracic surgery
• severe multilobar pneumonia

Question 10

ARDS symptoms

Answer 10

tachypnea
dyspnea
retraction
hypoxia
tachycardia
crackles

Question 11

causes of ARDS

Answer 11

• massive trauma
• severe respiratory disorder
• prolonged mechanical ventilation (white lungs)
• hemorrhagic shock
• fat emboli
• septic condition

Question 12

ABG’s of ARDS

Answer 12

• decreased PCO2
• increased dyspnea
• white lungs

Question 13

SIRS criteria

Answer 13

temperature >38.3 or 20 or PCO2 32mmHg

WBC >12,000, 10% bands

Question 14

sepsis criteria

Answer 14

SIRS + source of infection

Question 15

severe sepsis criteria

Answer 15

sepsis + organ dysfunction/hypoperfusion

-moltted skin, delayed capillary refill, UOP 2 mmol/L, altered mentation, coagulopathy/DIC, ARDS

Question 16

septic shock criteria

Answer 16

severe sepsis + persistent hypotension after adequate fluid challenge (40-60 ml/kg)

Question 17

MODS criteria

Answer 17

Multiple organ dysfunction

-progressive mutliorgan dysfunction/failure in setting of septic shock

Question 18

what antibiotics to give with S. pneumoniae, legionella, H. influenza, GNR’s, S. aureus, M. pneumonia, respiratory viruses (IVa)

Answer 18

beta-lactam plus macrolide
or
fluoroquinolone

Question 19

IVa organisms, P. aerugenosa, what antboitics to give

Answer 19

antipseudamonal beta-lactam PLUS

aminoglycoside AND macrolide or fluoroquiolone or fluoroquinolone

Question 20

what antibiotics for IVa organisms, P. aerugenosa and CA-MRSA

Answer 20

antipseudamonal beta-lactam PLUS
aminoglycoside AND macrolide or fluoroquiolone or fluoroquinolone
PLUS vancomycin

Question 21

shock states

Answer 21

CHF
septic
neurogenic
anaphylactic
hypovolemic

Question 22

CHF vitals

Answer 22

decreased CO
increased TPR
increased PCWP
-treat: diuresis, dobutamine

Question 23

septic vitals

Answer 23

increased CO
decreased TPR
decreased PCWP
-treat fluids, NE

Question 24

neurogenic

Answer 24

decreased CO, TPR, PCWP

-treat dopamine

Question 25

anaphylactic vitals

Answer 25

increased CO
decreased TPR, PCWP
-Epinephrine

Question 26

Hypovolemic vitals

Answer 26

decreased CO
increased TPR, PCWP
-treat: fluids, NE

Question 27

oxygen content in blood

Answer 27

Oxygen on HgB+ Oxygen plasma

1.34 x [HgB] x SaO2)+ (.0031 x PaO2

Question 28

oxygen delivery

Answer 28

CO X Oxygen content

-Q X CaO

Question 29

clinical exam signs of malperfusion

Answer 29

-altered mental status
-urine output
capillary refill
skin mottling
heart rate
blood pressure

Question 30

5 targets for goals of perfusion

Answer 30

-urine output .5 ml/kg/hr
-mean arterial pressure
lactate
central venous oxygen saturation
central venous pressure

Question 31

if have a patient that is intubated, and hypotensive s/p fluid challenge

Answer 31

-maybe want to do an IJ

Question 32

D-dimer

Answer 32

degradation product of cross linked fibrin

-very sensitive test

Question 33

ELISA test for D-dime

Answer 33

sensitive

long turn around time

Question 34

Latex agglutination test for D-dimer

Answer 34

more rapid

less sensitive

Question 35

CXR in PE

Answer 35

• 40% have normal CXR
• elevation of ipsilateral hemidiaphragm
• platelike atelectasis
• westermark sign (no blood flow)
• enlarged proximal PA
• Cor pulmonale (dilatation of right heart)
• hamptoms hump (b/c of infarct)
• pleural effusion

Question 36

ECG findings for PE

Answer 36

-sinus tachycardia
-P. pulmonae
RBBB
right axis deviation
S1Q3T3

Question 37

PE presents with

Answer 37

respiratory alkalosis with hypoxemia

Question 38

work-up for suspected PE with renal insufficency

Answer 38

D-dimer and clinical assessment
venous ultrasound
V/Q scan (if ultrasound negative)
if V/Q negative: serial ultrasound

Question 39

treatment of PE

Answer 39

heparin
LMWH: with malignancy, warfarin better
fondaparinux: factor Xa inhibitor, subcut.
direct thrombin inhibitors (argatroban): allergic to herpain
warfarin
new oral factor Xa inhibitors
IVC filter: if unable to anticoagulate