ITE Crit Care 2 Flashcards by Nebuchadnezzer II

Any abx that treats GNB may directly cause lysis and release ____

outer bacterial membrane, Lipopolysaccharide

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How does TPN cause hypophosphatemia?

Glucose loading –>
cellular uptake of glucose and phosphate

*often, phosphate is added to TPN when first started

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3 causes of severe hypophosphatemia in ICU setting

refeeding syndrome
DKA
Large decreases in PCO2 (hyperventilation)

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Refeeding syndrome symptoms (4)

Respiratory insufficiency
Rhabdo
Red cell dysfunction
Sudden death

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_________ is the most common cause of distributive shock characterized by severe peripheral vasodilation

septic shock

- high cardiac output state (9L)

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Obstructive shock is mostly d/t _____ causes of cardiac pump failure and often associated with poor RV output and increased systemic vascular resistance

extracardiac

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Normal cardiac output in L/min

5 L/min

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Non anion gap metabolic acidosis is used to determine ______

if the kidneys are functioning appropriately and acidifying urine in the setting of systemic acidosis
- the kidneys also serve as the body’s primary means of eliminating excess H+ during acidemia

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_________ is used to differentiate between etiologies of non-anion gap metabolic acidoses

Urine anion gap aka urinary strong in difference

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How to measure urine anion gap. What is normal?

Na + K + Cl

Nl: 0-5 mEq/L

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If the urine anion gap is NEGATIVE, this indicates a higher than expected amt of NH4+, indicating __________ response to systemic acidosis.

appropriate

- by acidifying the urine through trapping of H+ in the NH4+ molecule

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Type 1 renal tubular acidosis is caused by a failure of the kidney to excrete H+ in the ____ part of the nephron, and results in (excess/poor) secretion of potassium

distal nephron

excess
- HYPOKALEMIA

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Type I RTA is a classic presentation of systemic acidemia and paradoxical _____.

hypokalemia

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Type __ RTA will cause hyponatremia and hyperkalemia

Type 4 RTA

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When renal secretion of H+ is impaired (RTA), the urine anion gap will be _____, despite a systemic acidosis

neutral or elevated

Normal urine anion gap is 0-5 mEq/L

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______ can be used for prophylaxis against chemical warfare nerve agents soman, sarin gas, and VX, which all act as acetylcholinesterase inhibitors (organophosphate poisoning)

pyridostigmine

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Cholinergic effects

SLUDGE ME

Salivation
Lacrimation
Urination
Defecation
GI distress
Emesis
Miosis

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_____ is a drug that binds to acetylcholinesterases that have been inactivated by organophosphate compound, causing the organophosphate compound to dissociate and allowing the acetylcholinesterase to become active again. (removes nerve agent from binding site on enzyme)

Pralidoxime

- Cannot cross BBB

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Treatment for nerve agent exposure (not prophylaxis)

Atropine or pralidoxime

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_____ is an anti-muscarinic that can be used to treat the muscarinic effects of nerve agents, but not prophylaxis

atropine

*only one that can cross BBB

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_____ is a cholinergic agent which helps attenuate/block muscarinic effects of nerve gasses. _____is an acetylcholinesterase reactivator and actively removes nerve agent from the binding site on the enzyme

atropine

pralidoxime

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_____ and ____ can manage acid-base status during CPB, where hypothermia plays a major role in reducing cerebral metabolic demands

pH stat, alpha stat

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______ management technique corrects the alkaline drift by maintaining a neutral pH during hypothermia during CPB

pH stat

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______ management allows the natural alkaline drift to occur without correction during CPB

alpha-stat

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Disadvantages of pH-stat

increased delivery of embolic load to the brain Loss of cerebral autoregulation

_____ management couples CBF with CMRO2 during CPB

alpha stat

_______ controlled ventilation is characterized by decelerating inspiratory flow rate and more homogenous distribution of tidal ventilation across alveoli with different time constants

pressure | - as well as constant inspiratory pressure

______ controlled ventilation is characterized by constant inspiratory flow delivery

volume | - as well as achieving same tidal volumes regardless of changes to external factors

With volume controlled ventilation, ______ may fluctuate depending on increase or decrease in respiratory system compliance or airway resistance

airway pressure

With pressure controlled ventilation, _______, may fluctuate with altering respiratory system compliance or airway resistance

tidal volumes

(Pressure/Volume) controlled ventilation is associated with higher mean airway pressure

Pressure controlled ventilation

(Pressure/Volume) controlled ventilation is associated with more homogenous distribution of tidal ventilation

pressure controlled ventilation

Hypoxic ischemic encephalopathy sx

cerebral edema and elevated ICPs

After drowning, victims lungs looks show (consolidations/pulmonary edema)

generalized pulmonary edema

tidal volumes should be based off of people's (height/weight)

height

(pressure/volume) control mode ventilation will result in lower peak airway pressure

Pressure

Predicted weight in men vs women

women: height (cm) - 110 men: height (cm) - 105

Hematologic manifestations of hypophosphatemia

immune dysfunction and higher risk of sepsis

Hypophosphatemia will decrease production of 2,3-DPG and shift the oxygen dissociation to the (Right/Left)

Left - decrease oxygen delivery to the tissues - oxygen will dissociate from hgb at a lower PaO2

How do drowning lung injuries result in V/P mismatch?

Forced inhalation against a closed glottis during laryngospasm -> Pumonary edema -> decrease lung compliance -> V/P mismatch

If hypertonic seawater is aspirated what happens to the lungs compared to freshwater?

Seawater: - hypertonic solution draws more fluid into the alveoli and pulmonary interstitium -> worse pulmonary edema Freshwater: - rapidly absorbed into the circulation, resulting in potential transient hypervolemia and eventual pulmonary edema as fluid is redistributed

Drowning victim of hypotonic fresh water results in ____ of the blood vessels. Blirubin will show _____ and urine will show

hemolysis hyperbilirubinemia hemoglobinuria

Serratia marcescens is a GNB that grows in indwelling catheters and is naturally resistant to _____

ampicillin, macrolides, 1st gen cephalosporins

Tx choice for serratia is usually _____

Aminoglycosides

Treatment choice of E. faecalis is (PCN/Ampicillin). ____ is reserved for resistant cases

ampicillin. Linezolid, dapto

_______ is superior to H2 blockers (cimetidine, ranitidine) in preventing ventilator-associated PNA, while _______increases the risk of ventilator-associated PNA

Sucralfate PPIs (pantoprazole)

The ____ view on TTE allows visualization of the RV and LV as well as the ventricular septum.

Parasternal short axis

In the setting of acute cocaine use, pts MAC (increases/decreases)

increases

_____ is used in management of HTN and tachycardia in pts with NSTE-ACE and signs of acute cocaine or methamphetamine intoxication

BDZ +/- nitroglycerin

Structural heart changes seen in chronic Cocaine use

LVH | dilated cardiomyopathy

Rate of transmission from contaminated needle - HIV - HCV - HBV

- HIV: 0.3% - HCV: 0.5% - HBV: 30%

Normal values for: CVP: RA pressure: RV systolic pressure: RV end-diastolic pressure: PA systolic pressure: PA end-diastolic pressure: Mean PAP: Pulm cap wedge pressure aka LVEDP:

CVP: 0-7 RA pressure: 0-7 RV systolic pressure: 15-25 RV end-diastolic pressure: 3-12 PA systolic pressure: 15-25 PA end-diastolic pressure: 8-15 Mean PAP: 10-22 Pulm cap wedge pressure/LVEDP: 6-15

Obstructive shock is caused by extra cardiac conditions that lead to poor _____. This can be divided into ___ and ____

poor RV output pulmonary vascular and mechanical

Septic Shock What gets affected 1st: What is the response mechanism:

Decrease SVR increase CO

Cardiogenic shock What gets affected 1st: What is the response mechanism:

Increase LVEDP aka PCWP aka LV preload increase SVR

Cardiac tamponade What gets affected 1st: What is the response mechanism:

Increase PAP aka Pressure after RH and LVEDP aka PCWP aka LV preload response: increase SVR

PE What gets affected 1st: What is the response mechanism:

PVR (a measured value via swan ganz, thermal dilution, TEE) response: increase SVR

Hypovolemic shock What gets affected 1st: What is the response mechanism:

Decrease CVP Increase SVR

Neurogenic shock What gets affected 1st: What is the response mechanism:

Decrease CO (spinal shock/bradycardia) no sympathetic response

Vasoconstrictors (increase / decrease) venous compliance

decrease * highly compliant veins: soft flexible tube * Decreased compliance: hard stiff tube

Angiotensin II leads to venous (constriction / dilation)

Constriction | - decrease compliance

Adenosine and furosemide (increase / decrease) venous compliance

increase | - both have venodilating properties

Compounds that are significantly metabolized by the pulmonary cells

1. Norepi 2. Serotonin 3. Bradykinin 4. Angiotensin-1

Organophosphate, parathion, malathion, fenthion result in cholinergic toxicity (increase ACh in nicotinic and muscarinic synapse. Sx?

1. Miosis 2. Salivation 3. Lacrimation 4. Urination 5. Diarrhea 6. GI cramps 7. Emesis 8. Bronchoconstriction 9. Muscle weakness *Sludge + Miosis + bronchoconstriction + muscle weakness

Intraabdominal HTN is defined as IAP > ____ mmHg

> 12 mmHg

Pulsus paradoxus (seen with tamponade or constrictive pericarditis) occurs when the heart is dependent on (positive/negative) intrathoracic pressure

negative - venous return is highly dependent on neg intrathoracic pressure during spontaneous ventilation - Positive pressure ventilation can cause hemodynamic collapse

Distant heart sounds is not diagnostic of tamponade. What is pathognomonic for it?

Beck's triad 1. Hypotension 2. Distended neck veins 3. Muffled/distant heart sounds

When are ACE-i contraindicated?

1. Pregnancy (teratogenic) 2. Angioedema 3. Allergy to ACE-i

The RAAS is responsible for releasing ____ into plasma with _____

Renin 1. Hypotension 2. Hyponatremia 3. B1-receptor activation