ITE Crit Care 2 Flashcards
Any abx that treats GNB may directly cause lysis and release ____
outer bacterial membrane, Lipopolysaccharide
How does TPN cause hypophosphatemia?
Glucose loading –>
cellular uptake of glucose and phosphate
*often, phosphate is added to TPN when first started
3 causes of severe hypophosphatemia in ICU setting
- refeeding syndrome
- DKA
- Large decreases in PCO2 (hyperventilation)
Refeeding syndrome symptoms (4)
- Respiratory insufficiency
- Rhabdo
- Red cell dysfunction
- Sudden death
_________ is the most common cause of distributive shock characterized by severe peripheral vasodilation
septic shock
- high cardiac output state (9L)
Obstructive shock is mostly d/t _____ causes of cardiac pump failure and often associated with poor RV output and increased systemic vascular resistance
extracardiac
Normal cardiac output in L/min
5 L/min
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
_________ is used to differentiate between etiologies of non-anion gap metabolic acidoses
Urine anion gap aka urinary strong in difference
How to measure urine anion gap. What is normal?
Na + K + Cl
Nl: 0-5 mEq/L
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
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
Type I RTA is a classic presentation of systemic acidemia and paradoxical _____.
hypokalemia
Type __ RTA will cause hyponatremia and hyperkalemia
Type 4 RTA
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
______ can be used for prophylaxis against chemical warfare nerve agents soman, sarin gas, and VX, which all act as acetylcholinesterase inhibitors (organophosphate poisoning)
pyridostigmine
Cholinergic effects
SLUDGE ME
Salivation Lacrimation Urination Defecation GI distress Emesis Miosis
_____ 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
Treatment for nerve agent exposure (not prophylaxis)
Atropine or pralidoxime
_____ 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
_____ 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
_____ and ____ can manage acid-base status during CPB, where hypothermia plays a major role in reducing cerebral metabolic demands
pH stat, alpha stat
______ management technique corrects the alkaline drift by maintaining a neutral pH during hypothermia during CPB
pH stat
______ management allows the natural alkaline drift to occur without correction during CPB
alpha-stat
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
- Norepi
- Serotonin
- Bradykinin
- Angiotensin-1
Organophosphate, parathion, malathion, fenthion result in cholinergic toxicity (increase ACh in nicotinic and muscarinic synapse. Sx?
- Miosis
- Salivation
- Lacrimation
- Urination
- Diarrhea
- GI cramps
- Emesis
- Bronchoconstriction
- 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
- Hypotension
- Distended neck veins
- Muffled/distant heart sounds
When are ACE-i contraindicated?
- Pregnancy (teratogenic)
- Angioedema
- Allergy to ACE-i
The RAAS is responsible for releasing ____ into plasma with _____
Renin
- Hypotension
- Hyponatremia
- B1-receptor activation
