July MICU Deck Flashcards
Purpose of repleting K to 5 in COPD patient getting diuresis
COPD pts retain pCO2, want to prevent acidosis
Lasix dumps Cl (inhibits NKCC), causing kidneys to hold onto another anion, bicarb. Holding onto bicarb which neutralizes the CO2 being held onto => normalizes pH and reduces respirtory drive in COPDers
By repleting K you’re giving KCl…therefore getting rid of Na (and water) w/o losing Cl => w/o retaining bicarb
Diuretic that works synergistically w/ lasix
Metolazone = Diuril- inhibits NaCl transporter in the DCT
Mechanism of metolazone
Metolazone inhibits NaCl transporter in DCT
Explain physiology of why a hemothorax can cause lung collapse
Hemothorax (or really anything) makes the pressure in the pleural space more positive => less negative pressure of the chest wall holding the lung open = lung collapse
B/c at baseline negative pressure of chest wall vs. smaller positive pressure of lung elasticity keeps lung open
Mechanism of hyperventilation to decrease ICP
Hyperventilation => decreased CO2/alkalemia => cerebral vasoconstriction
Name the three chambers of a chest tube
- Drainage- collects fluid from patient
- Water seal- prevents backflow, also where you see air leak. Air from inside pt comes here and bubbles out => can’t go back into pt during expiration
- Suction chamber- open to air (so can’t exceed 20mmHg) and can connect to wall suction
Function of water chamber in chest tube
Water chamber
- prevents backflow of air back into chest: air can only move from high to low pressure => can only move out into water (that has suction on it) than back into chest wall
- lets you see if there is still air in the chest! (where you visualize air bubbles
Function of suction chamber in chest tube
Suction chamber open to both (1) air- sets a max suction at atmospheric -20 (2) external source = wall suction to provide the pressure to pull stuff out of the chest
-external source provides the amount of pressure actively suctioning the entire system
Explain the respiratory variation you’d expect to see in chest tube tubing
Expect to see fluid go slightly back into (towards) pt w/ inspiration b/c of negative inspiratory pressure
Explain how to chase lasix w/ metolazone
Metolazone (diuril) first to inhibit the NaCl transporters in the DCT, causing upregulation of the NKCC in the loop
Then 30-60 mins later give lasix- to bind to the more available NKCC channels and further have potent diuresis effect
Differentiate aspergilloma from invasive aspergillosis
Spectrum of disease ranging from just a fungus ball (aspergilloma) that doesn’t invade tissues to
invasive aspergillosis = see filamentous stuff in the actual tissue, typically seen in immunocompromised (leukemia)
Name a drug that can cause false-positive galactomannan
Galactomannan = beta-D glucan = serum marker for invasive aspergillosis, can be false positive in pts on PCN abx such as Pip-tazo
4 main adverse reactions to voriconazole
Voriconazole = antifungal (first line for aspergillus)
- visual disturbance/changes in 30%
- skin changes/dermatologic rash
- hepatitis (monitor LFTs)
- Drug-drug interactions: tons, prolongs QTc (watch w/ antipsychotics), can raise serum atorvastatin
Unexplained MAC in infertile M
Think CF (cystic fibrosis) -MAC usually needs some other pulmonary disease as substrate
Broad ACS algorithm for bradycardia
Get on monitor and pacers (quickly if unstable) , get 12-lead, atropine 0.5mg q3minutes then pace at 70 bpm, can start at 100 mA and decrease until find minimum voltage to capture
1st line medication for symptomatic bradycardia
Symptomatic brady (AMS, light-headed etc): atropine
Atropine 0.5mg IV q3 mins
Get EKG: atropine is an AV nodal blocker (anticholinergic) => works best on sinus brady, first degree AV block, maybbbe second degree type 1
But second degree type II and complete heart block definitely just need pacing
How to sedate someone before pacing for symptomatic/unstable bradycardia
Fentanyl 25 mcg + Versed (midazolam) 1 mg
Reversal agent for beta-blockers
Reverse beta-blocker (ex: symptomatic bradycardia): give 1 g IV glucagon
Reversal agent for calcium channel blockers
CCB reversal (ex: symptomatic bradycardia): can try first w/ 2g calcium -then escalate to high dose (like 1U/kg) insulin ggt w/ dextrose (of course uptriage to MICU)
Pharmacologic agents besides atropine to use in symptomatic bradycardia
Between atropine and pacing can potentially try some pressors, especially one w/ beta-chronotropic (increase HR) effect:
Epinephrine and dopamine (ggts)
30 yo w/ headache and unilateral vision loss
Central retinal artery occlusion, retinal detachment
But what to NOT consider = GCA, basically a non-started (incredibly rare) in pts under 50 yoa
First line tx for GCA
1g solumedrol (crazy high dose)
Criteria for ASCVD calculator
ASCVD calculator: ages 40-79, LDL 70-189, to determine 10-year risk of cardiovascular event
If gt 7.5% indication enough to start statin therapy
ACS algorithm for treatment of NSTEMI
NSTEMI = positive trop w/o EKG changes
- Aspirin load = 4 baby aspirin (324mg) then daily ASA 81
- Plavix load w/ plavix 300mg then daily clopidogrel 75mg
- Consider starting heparin ggt: can bolus then titrate to goal PTT 50-75 on q6 PTTs
Adenosine vs. atropine
Adenosine = AV nodal blocking agent to use in supraventricular tachycardias to unmask underlying rhythm
Atropine = anticholinergic to use for symptomatic bradycardia, best in sinus but also beneficial in first degree block
How to differentiate SVTs?
Adenosine (AV nodal blocking agent): push 6mg, AFib or AFlutter will come back after adenosine wears off (super short half life)
While AVNRT will revert to NSR bc blocking the SA node will block the reentrant pathway
Main electrolyte abnormality in refeeding syndrome
Hypophosphatemia
B/c you suddenly start eating so need tons of ATP for digestion => you replete your phos stores quickly
Main criteria/guidelines for cooling s/p arrest
- Out of hospital arrest for a shockable rhythm (VF, VT)
- ROSC w/in 60 minutes, now not following commands/non-verbal
- w/in 6 hrs of collapse
- no coagulopathy (normal INR)
Distinguish ICD for primary vs. secondary prevention
ICD
Primary prevention = prevent a first attack from occuring
-main indication is MI w/ EF under 35%, but MI more than 40 days in the past
Secondary prevention = prevent a second/future attack
-h/o VT/VF and hemodynamic instability w/o reversible cause
Main indications for ICD for primary prevention
ICD for primary prevention = to prevent a first attack from occurring
- MI more than 40 days ago with EF under 35%
- Known structural heart disease w/ inducible VT
- HF not improved on max medical management for at least 3 months
- Congenital prolonged QTC syndrome: Brugada, HOCM
NYHA classes of HF
NYHA = NY heart failure association classes are based on symptoms/exercise tolerance limitations
class I: physical disease w/o activity limitation
class II: physical disease w/ DOE on hard to moderate activity
class III: physical disease w/ marked DOE, pain/SOB/symptoms on 2-5 METS (walking at 2.5mph)
class IV: symptoms at even lower METS
Beta-blocker(s) w/ mortality benefit in HF
in HF use: metoprolol succinate (the long acting) or carvedilol (coreg)
Why may carvedilol be better than metoprolol in HF
Metoprolol is a beta-1 specific beta-blocker, while coreg (carvedilol) blocks beta1, beta2, and alpha1
alpha1 blockade may help reduction in afterload
Anesthesia asks you to stop chest compresisons so they can intubate…
NOO!!! Chest compressions are keeping them perfused
Either tell them to figure it out or ask for an LMA
Why do you want intubation so badly in a code situation?
Of course to secure airway and get O2 to the lungs, but that’ll passively kind of happen anyway…
You want end tidal CO2 so you can gauge adequacy of chest compressions
What to use for urgent needle decompression in tension pneumothorax
Ideal would be a 16-18 guage angiocath
Angiocath and not needle b/c then you can remove needle (so person doing compressions doesn’t get stuck) but pleural space stays open to air
But if leaving in angiocath you’ll want a waterseal on it (to prevent air blackflow in pleural space on inspiration)
