kettering section g: pathology Flashcards
1
Q
Respiratory care for Guillain Barre patient
A
- Closely monitor Vt, VC, NIF should intubation/mechanical ventilation be indicated
- Oxygen therapy for hypoxemia
- Hyperinflation therapy (IS/SMI, IPPB)
- Pulmonary hygiene
2
Q
Disease-modifying treatment for Guillian-Barre
A
- Either plasma exchange or intravenous immune globulin (IVIG)
- Not recommended to do both plasma exchange and IVIG
- Do not use glucocorticoids
(UTD)
3
Q
What findings would be typical in primary assessment of Guillian-Barre patient?
A
- Febrile illness in last 1-4 weeks, often viral in nature
- Acute weakness, especially in the legs
- Shallow breathing
- Diminished breath sounds
4
Q
What findings would be typical in secondary assessment of Guillian-Barre patient?
A
- PFTs: Decreased Vt, FVC, NIF
- ABG: acute ventilatory failure with hypoxemia; watch for PaCO2 > 45 mmHg
- Lumbar puncture: high protein level in CSF
- Electromyography: abnormal
- Nerve conduction studies: abnormal (Kettering, UTD, CMARD)
5
Q
What stressors can provoke clinical manifestations of myasthenia gravis?
A
- Emotional upset
- Physical stress
- Exposure to extreme temperature changes
- Pregnancy
- Febrile illness
6
Q
What primary assessment findings would be typical for myasthenia gravis exacerbation?
A
- Gradual onset of weakness
- Previous admissions for MG
- Weakness improves with rest
- Ptosis
- Diplopia
- Dysphagia
- Shallow breathing
- Diminished
7
Q
What secondary assessment findings would be typical for myasthenia gravis?
A
- Decreasing Vt, VC, NIF
- Acute ventilatory failure with hypoxemia watch for PaCO2 > 45 mmHg
- Reduced Vt, FVC
8
Q
What test is given to assess myasthenia gravis?
A
Tensilon test
9
Q
How is the tensilon test interpreted?
A
If Vt, VC, NIF, and weakness improve with Tensilon: Myasthenic crisis.
If Vt, VC, NIF, and weakness worsen with Tensilon: Cholinergic crisis.
10
Q
Maintenance drugs for myasthenia gravis
A
Prostigmine (Neostigmine)
Pyridostigmine (Mestinon, Regonol)
11
Q
What class of drugs is indicated for myasthenia gravis?
A
anticholinesterase therapy
cholinesterase inhibitors
12
Q
What medication should be given for myasthenia gravis patient caught in a cholinergic crisis?
A
Atropine will relieve the symptoms of a cholinergic crisis.
13
Q
What psychiatric morbidity is common after critical illness?
A
Depression
Anxiety
Post-traumatic stress disorder
14
Q
What percentage of ARDS survivors will experience chronic cognitive impairment?
A
70-78%
15
Q
What percentage of ICU survivors will experience chronic cognitive impairment?
A
25-78%
16
Q
Generally define “cognitive ability.”
A
The way a person experiences and thinks about the world.
17
Q
What capacities could be impaired in a person with cognitive impairment?
A
Intelligence Attention Learning Memory Language Visual/spatial skills
18
Q
What elements of executive function could be impaired in a patient with cognitive impairment?
A
Reasoning Decision making Planning Problem solving Working memory Sequencing Control
19
Q
Define delirium.
A
An acute behavioral disturbance characterized by
- Acute confusion
- Inattention
- Disorganized thinking
- Fluctuating mental status
20
Q
Name subtypes of delirium.
A
- Hypoactive or quiet delirium
- Hyperactive delirium
- -though delirium is dynamic and can fluctuate between hypo- and hyperactive types
21
Q
Describe hypoactive delirium.
A
Reduced mental & physical activity
Inattention
22
Q
Describe hyperactive delerium
A
Agitation
Combativeness
At risk for self-extubation, pulling lines, falling
23
Q
Is ICU delirium a permanent state?
A
Kettering: No, ICU delirium is temporary
24
Q
The immunosuppression of HIV can lead to what categories of conditions?
A
- Opportunistic infections (such as pneumonias)
- Secondary neoplasms
- Neurologic manifestations
25
What opportunistic pulmonary infections can plague people with HIV?
* Pneumocystis carini/jiroveci
* Toxoplasmosis
* Candidiasis (esophageal, tracheal, pulmonary
* Mycobacteriosis (atypical TB)
26
Name populations at risk for HIV.
* Homosexual/bisexual men
* IV drug abusers
* Recipients of blood transfusion (e.g., patients with hemophilia)
* Imprisoned people
27
Name the three phases in which systemic immune complex diseases develop.
1. Formation of antigen-antibody complexes in circulation.
2. Deposition of immune complexes in various tissues.
3. Inflammatory reactions in various sites throughout the body.
28
What results from the 3 phases of systemic immune complex disease development?
Vasoconstriction and edema
29
What happens during transplant organ rejection?
An immunological reaction causing hypersensitivity response of the host to the donor organ.
30
How do burns affect the cardiovascular system?
* Increased capillary permeability & fluid loss result in hypovolemia.
* Loss of fluids decreases preload and cardiac output.
* After 24-48 hours, inflammatory mediators influence cardiac contraction and relaxation.
31
How should the myocardial depression of burn injury be treated?
Fluids
| Inotropic agents
32
What challenges complicate blood pressure monitoring in burn patients?
* Post-burn edema decreases accuracy of cuff blood pressure
| * Vasoconstriction from catecholamine release decreases accuracy of arterial blood pressure
33
Signs and symptoms of cyanide poisoning.
```
Lethargy
Nausea
Headache
Weakness
Coma
Decreased Ca-vO2
Severe metabolic acidosis
Unresponsiveness to fluids or oxygen
ST elevation possible on EKG
```
34
Treatment for cyanide poisoning
* 100% oxygen (Kettering)
* Inhaled amyl nitrate pearls Kettering)
* Hydroxocobalamine (Cyanokit)
35
The asphyxiant gases and hypoxic environments of house fires.
* FiO2 < 0.21
* Carbon monoxide
* Cyanide
36
Fire environment insults to pulmonary system
Inflammation
Acid-base imbalance
Airway injury
Chest wall constriction
37
Watch for these pulmonary problems in smoke inhalation
* Transient pulmonary hypertension
* Decreased lung compliance
* Hypoxia
38
Infections of burn wounds may have what pulmonary consequence?
ARDS
39
Why might burn injury patients be extubated early?
To avoid VAP and tracheal stenosis.
40
What percentage of burn patients suffer from smoke inhalation injury?
10-30%
41
How should upper airway edema in the burn patient be treated?
With standard therapy--
* cool aerosol
* oxygen
* racemic epinephrine
42
What intervention can be considered for severe inhalation injury?
Intrapulmonary percussive ventilation (IPV)
43
What clinical events common to burn patients might lead to early renal failure?
- -Delayed resuscitation
- -Hypotension
- -Rhabdomyolysis (especially with electrical burns)
44
What developments in burn patients may lead to late renal failure?
* Sepsis
* Toxic medications
* Pre-existing conditions
45
Early responses to renal failure in burn patients.
* Fluid resuscitation
* Monitor I/Os
* Monitor lines for sepsis
* Monitor for pneumonia
* Monitor for urinary tract infections
- -Some patient may eventually require dialysis
46
Measures for GI system in burn patients.
- -Watch for ileus, common in patients with burns > 20% TBSA
| - -Start early feeding, oral or enteral
47
What endocrine system changes can be anticipated in burn patients?
- -Hypothalamus secretes antidiuretic hormone to increase fluid retention
- -Adrenocorticotropic hormones release aldosterone & glucocorticoid cortisol
- -Neurotransmitters adrenaline & noradrenaline released.
48
Burn patients suffer these hematopoietic system effects relevant to respiratory care.
Decreased RBCs, Hgb, Hct. with resulting decreased oxygen carrying capacity.
49
Anticipate these alternations to the immune system in burn patients.
- -Risk of infection that rises in direct relation to size of burn
- -Loss of barrier function in burned skin, allowing pathogens passage to the body
50
Kettering guides to ventilating bariatric patients.
* Key Vt to IBW rather than actual weight
* Set Vts at 6-8 mL/kg IBW for lung protection
* Use PEEP to offset chest weight
(monitor for decreased venous return/cardiac output/BP)
* Avoid common problem of pt/ventilator asynchrony (use spontaneous modes of ventilation; PS may be useful)
* Elevate head of bed to prevent aspiration & VAP
* Consider early extubation to NPPV or CPAP
51
What features, in obese patients, correlate with difficult intubation?
* Large or bull neck
| * Mallampati score >= 3
52
Take these actions if snoring with daytime somnolence and/or apneic periods are observed in obese patient.
* Evaluate with sleep study at discharge
* Provide CPAP or BPAP post-operatively
* Use a simple evaluation tool such as the Epworth Sleepiness Scale
53
Common risks for obese patients
* Aspiration
* Inadequate ventilation via BVM
* Difficult intubation
* Hypoxemia secondary to apnea
* Atelectasis
* Hemodynamic instability
* DVT and pulmonary embolism
* Post-op respiratory dysfunction
* Delayed recovery from surgery
* Decreased ability to respond to stress (fr HTN to hyperglycemia)
54
What is the connection between obesity and rhabdomyolysis?
* The two often connected
* Also called "Pressure-induced myoglobinuria"
* Caused by excessive pressure on tissue from body weight
55
How does one watch for rhabdomyolysis in the obese patient?
* Watch for dark or brown urine
* Watch for acute renal failure
* Monitor CPK
56
How does one treat rhabdomyolysis in the obese patient?
Treat aggressively with fluids.
57
(Kettering) What medical conditions are associated with OSA in the obese?
* Obesity Hypoventilation Syndrome (OHS)
* Pickwickian Syndrome
* Compensated respiratory acidosis
* Cor pulmonale
58
Circulatory conditions common preoperatively in obese patients?
Systemic HTN
| Pulmonary HTN
59
How is "obesity" defined?
BMI >= 30 kg/m2
60
Supportive treatment for Guillien-Barré:
* Manage initially in the ICU because patients are at risk of neuromuscular respiratory failure and severe autonomic dysfunction.
* Monitor VC and NIF while weakness is progressing should mechanical ventilation be indicated.
* Monitor heart rhythms and blood pressure against development of arrhythmias--sinus tachycardia most common problem.
* Daily auscultation for bowel silence and development of adynamic ileus.
* Manage pain primarily with gabapentin or carbamazepine.
61
What is apheresis?
The general technique of extracorporeal blood purification whereby one constituent is removed (by centrifugation or membrane filtration) and the remainder is returned to the patient. (LITFL)
62
What is plasmapheresis?
A subset of apheresis-- blood purification technique designed for removal of large molecular weight substances from the plasma; the plasma is removed by centrifigation or membrane filtration and is replaced with "cleaned" autologous plasma or by donor plasma or by another replacement colloid solution ("plasma exchange"). (LITFL)
63
Considering post-injury resuscitation for orthopedic trauma, what constitutes the acute period?
12-24 hours
64
Resuscitation goals following orthopedic trauma should be concerned with what principles?
* Optimizing tissue perfusion
* Ensuring normothermia
* Restoring coagulation
65
What is the goal-directed therapy for post-injury resuscitation in orthopedic trauma?
* Hemoglobin > 10 g/dL
* Cardiac index > 3.8 L/min/m2
* Oxygen delivery DO2 > 500mL/min/m2
* Temperature > 35ºC
* Base excess: ≥ -6
* Normal coagulation indices
66
Patient recovering from orthopedic trauma has ongoing need for pressers. What condition should the clinician consider?
Adrenal insufficiency.
67
What areas are most at risk in blunt trauma injuries?
* Liver
* Spleen
* Pancreas
* Mesenteric arteries
68
How should blunt trauma injuries to abdominal organs be assessed?
With ultrasound and/or peritoneal lavage.
69
Considerations for abdominal aortic injuries in trauma.
* They present primarily with signs/symptoms of hypotension
* They can be diagnosed with ultrasound
* They may be life-threatening
70
In instances of facial trauma, what is the highest priority?
Managing the airway
—use chin-lift/jaw thrust to open airway
—prepare for emergent tracheostomy/cricothyrotomy
71
What conditions in facial trauma indicate intubation?
* Glasgow Coma Scale <9
* Sustained seizure
* Unstable midface trauma
* Direct injury to airway
* Aspiration risk
* Oxygenation problems
72
What does ORIF stand for?
Open Reduction Internal Fixation
73
Why does orthopedic trauma require vigilance?
* Missed fractures cause significant morbidity & mortality
* Unrecognized ischemia or compartment syndrome may result in amputation
* Unrecognized ischemia can produce life-threatening rhabdomyolysis and resulting electrolyte imbalance
* Fracture hematoma can cause SIRS and multiple organ failure
74
How does fat embolism syndrome from long bone fractures present?
Classic triad:
- -hypoxemia (Kettering: ARDS)
- -neurological abnormalities
- -characteristic red-brown petechial rash
75
Prolonged post-op care for orthopedic trauma may result in what lethal triad that can leave a patient dead in 24 hours?
* Acidosis
* Coagulopathy
* Hypothermia
76
Kettering’s points for spinal cord injury, respiratory failure, and intubation
* Elect early intubation
* Consider hypoxia and hypercapnea to be *late* signs of respiratory failure
* Intubate if VC < 10mL/kg
* Intubate if NIF < -20 cmH2O
* Note that NPPV is contraindicated
77
What are the most common causes of death in patients with spinal cord injury?
* Pneumonia
* Septicemia
* Pulmonary embolism
78
Two key features of shock due to neurological causes
* Loss of peripheral vasoconstriction
| * Loss of cardiac compensation
79
Treatment for shock due to neurological problems
* Volume resuscitation
* Vasoactive medications: norepinephrine, dopamine, & phenylephrine
* Methylprednisolone within 8 hours of injury for > 23 hours (may increase rate of respiratory complications)
80
How does Kettering say to clear cervical spine?
* Normal flexion/extension films
| * Normal MRI within 48 hours
81
Secondary injuries from spinal cord injury--those beyond injury from cord compression.
```
Systemic and vascular insults—
• Hypotension
• Electrolyte imbalance
• Edema
• Excitotoxicity
```
82
Kettering’s definition of trauma
Any bodily injury caused by any kind of accident—motor vehicle crash, etc.
83
What circumstances typically give rise to decelerating trauma?
MVC
84
What are the initial tasks of trauma care?
* Secure airway—assume injury to cervical spine and full stomach
* Support ventilation and oxygenation
* Support circulation and perfusion
* Goal-directed therapy to the end points of C.I., DO2, SvO2
85
Emergent treatment for tension pneumothorax
* 14-16 gauge IV catheter inserted into 2nd or 3rd intercostal space in the mid-clavicular line
* Follow with chest tube insertion
* Give fluids to maintain cardiac output
86
Emergent treatment for flail chest.
* Stabilize chest wall
| * Consider mechanical ventilation
87
Emergent treatment flail chest or sucking chest wound.
* Insert chest tube
* Endotracheal intubation
* Cover sucking chest wound to seal opening
88
Classically, how is cardiac tamponade/hemopericardium said to present present clinically ?
By Beck’s Triad:
• Hypotension
• Jugular venous distention
• Muffled heart sounds
Note that pulses paradoxes may be present.
89
Treatment for cardiac tamponade
* Pericardiocentesis
* Subxiphoid pericardial window preferred
* Thoracotomy in ED
* Note that decompression only buys time
* Avoid positive pressure ventilation to minimize effects on venous return
90
What preparation does Kettering recommend to meet the fluid requirements of an incoming trauma patient?
* Prepare to place two large-bore IV lines (for blood products)
* Commercial warming equipment
* Simple IV pressure bags
* Colloid, crystalloid, & blood products
91
Why are pressure bags required for IV lines?
* To increase transfusion pressure
| * To increase transfusion volume
92
Name the leading crystalloids
* Normal saline
| * Lactated Ringer’s
93
How much crystalloid is required to replace blood?
* 3L crystalloid required to replace 1L of lost blood
* Crystalloid equilibrates in interstitial and intercellular spaces
* Crystalloid, however, lacks the oxygen delivery power of RBCs
94
How do subdural hematomas form?
* May occur during a decelerating injury
| * Results from sheering of veins between brain and venous sinuses
95
How does an SDH appear on CT scan?
As a crescent-shaped hyperdensity that follows the contour of the brain (also in Hess 1017)
96
What kind of CT scan should we order for SDH?
A CT without contrast—since contrast dye can increase ICP
97
What mortality is associated with SDH?
5-60% mortality!
98
What condition is commonly associated with epidural hematoma?
Skull fracture
99
How do patients with epidural hematoma present?
Awake and alert—then then become comatose
100
What mortality is associated with epidural hematoma?
With surgical evacuation, mortality comes down to 5-10%
101
What conditions form the TBI family?
* SDH
* Epidural hematoma
* Cerebral contusion
* Intraventricular hemorrhage
* Subarachnoid hemorrhage
* Diffuse axonal injury
102
How should ICP, MAP and CPP be managed, according to Kettering?
—Maintain ICP no higher than 20-26
—Maintain mean arterial pressure > 90 mmHg
—Maintain cerebral perfusion pressure (CPP) > 60 mmHg
103
For the TBI patient—stabilize critical life functions and place cervical spine in precautions—and then assess—
* Level of consciousness (ability to speak, follow commands, vision and pupillary response)
* Perform ice water caloric reflex test
* Assess Glasgow Coma Scale
104
What might the ice water caloric reflex test reveal?
May indicate brainstem injury.
105
What is malignant hyperthermia?
A rapidly increasing temperature caused by uncontrolled skeletal muscle metabolism leading to rhabdomyolysis and death
106
Name anesthesia reversal agents for neuromuscular blocking agents.
Anticholinesterase (neostigmine, edrophonium, pyridostigmine)
Anticholinergic (atropine, glycopyrrolate)
107
What med is the old-school treatment for post-op delerium? What kind of drug is it? What side effects does it have and not have?
Haloperidol
Which is an antipsychotic with minimal hypotensive effects
With the potential side effect of Torsades de Pointes
108
What consequences follow from uncontrolled pain the the post-op patient?
Sympathetic nervous stimulation
- -elevates catecholamine levels
- -tachycardia
- -hypertension
- -increased SVR
- -increased myocardial O2 consumption
109
What consequences follow from upper abdominal and thoracic pain in post-op patients?
- -Inability to breathe deeply
- -Inability to cough
- -Development of atelectasis
- -Retained secretions
- -Hypoxemia
- -Pneumonia
110
Name causes of hypoxemia post-operatively.
* Residual anesthesia or muscle relaxant
* Upper airway obstruction due to decreased level of consciousness
* Pulmonary Edema
* Cardiac ischemia
111
Name causes of post-operative pulmonary edema.
* Heart failure
* ARDS
* Aspiration
* Infection
* Trauma
* Transfusion reaction
* Neurogenic pulmonary edema from head injury/trauma
112
What is negative pressure pulmonary edema?
Pulmonary edema developing after strenuous inspiratory effort against an obstructed airway
* May develop up to 10 hours after effort
* Occurs typically in young, vigorous adult who had laryngospasm
* Treatment is support
113
What broad changes can occur during malignant hyperthermia?
- -Oxygen consumption can increase three fold
| - -Blood lactate can increase 15-20 fold
114
What are the signs of malignant hyperthermia?
- -Skeletal muscle rigidity
- -Tachycardia
- -Hypertension
- -Increased PetCO2
- -Acidosis
- -Arrhythmias
- -Hyperthermia (body temperature may be >109degrees F
- -Cyanosis
- -Electrolyte abnormalities
- -Increased creatinine
- -Myoglobinuria
- -Coagulopathy
- -Cardiac failure
- -Pulmonary edema
115
When patient presents more than one sign of malignant hyperthermia, what further assessment is warranted?
- -Draw ABG
- -Draw central venous blood gas
- -Evaluate for respiratory acidosis and hyperkalemia
116
How should malignant hyperthermia be treated?
* Discontinue anesthetics (to stop the triggering agent)
* Hyperventilate with 100% oxygen (to compensate for acidosis)
* Dantrolene sodium (for muscle relaxation)
* Sodium bicarbonate (for severe acidosis)
* Apply ice, cold fluids, cooling blanket, heat exchanger (to control fever)
* Monitor intake/output
117
How does dantrolene sodium work?
Dantrolene sodium is a postsynaptic muscle relaxant that lessens excitation-contraction coupling in muscle cells. It inhibits the release of Ca2+ ions from sarcoplasmic reticulum stores by antagonizing ryanodine receptors. (W)
118
How is diagnosis of cystic fibrosis secured?
- -Sweat chloride test
- -Chloride level > 60mEq/L positive for CF
- -Two positive tests required to confirm diagnosis
- -In-utero genetic testing now available
119
Which organs are affected by CF?
* Lungs
* Pancreas
* Liver
* GI tract
120
What digestive problems plague people with CF?
* Hypoproteinemia & malnutrition (from lack of digestive enzymes)
* Diabetes 1 or 2 (can be caused by pancreatic problems
121
What about the noses of patients with CF?
* Sinus infections and nasal polyps common
| * Nasal intubation may be contraindicated
122
Name common bacteria behind cystic fibrosis pneumonia.
```
●Pseudomonas aeruginosa
●Staphylococcus aureus (methicillin-sensitive or methicillin-resistant species)
●Burkholderia cepacia complex
●Nontypeable Haemophilus influenzae
●Stenotrophomonas maltophilia
●Achromobacter species
●Nontuberculous mycobacteria
(UTD)
```
123
Common secondary pulmonary problem for patients with cystic fibrosis.
Bronchiectasis.
124
Why are patients with cystic fibrosis so thin?
* GI tract lacks digestive enzymes
* Hypoproteinemia
* Malnutrition
125
Why do people with cystic fibrosis get diabetes?
Because of problems with pancreas.
126
How might PE appear on EKG?
Anterior t-wave inversion.
127
Should you order a CXR for PE?
* Not helpful for PE.
| * May r/o other processes.
128
How might CXR suggest PE?
* Abrupt cutoff of pulmonary artery
* Focal oligemia (localized engorged vessels)
* Distention of proximal portion of pulmonary artery
- -Classic "wedge-shaped infiltrate" is rarely seen
129
What is the imaging of choice for PE?
Spiral CT with contrast dye
130
What test is helpful for PE for a hemodynamically unstable patient?
Echocardiogram--can help differentiate PE from non-PE events.
131
What echocardiogram findings are suggestive of PE?
* Right-sided thrombi
* Right ventricular dilation
* Hypokinesis
* Tricuspid regurgitation
* Paradoxical shift of ventricular septum
132
Name the hemodynamic changes in pulmonary embolism.
* Increased PVR
* Increased right heart afterload
* Increased PAP
* Increased MPAP
* Decreased left-heart preload
133
How does PE cause hypoxia?
* Increased alveolar deadspace
* V/Q mismatch
* Right to left shunting
* Decreased mixed venous oxygen saturation (with cardiogenic shock)
134
How can DVT be detected?
* Lower limb venography
| * Compression ultrasound in ICU
135
Why does DVT pose a problem?
* DVT often goes undiagnosed
| * Risk following major surgery or trauma in absence of prophylaxis
136
Common causes of DVT.
- -Blood clot that has migrated from another location
| - -Fatty embolism following traumatic long-bone fracture
137
What happens when mechanical ventilation is initiated in the patient with pulmonary hypertension?
* RV afterload increases
* RV preload decreases
* PEEP--increases PAP and PVR
* Permissive hypercapnea--increases PAP and PVR
138
How should hemodynamically unstable pulmonary hypertension be treated?
Vasopressors--
* Dobutamine reduces PVR and increases cardiac output
* Also increases shunting and may decrease oxygenation
139
Name the prostacyclins--generic and commercial names
* Epoprostenol (Flolan)
* Treprostinil (Tyvaso)
* Iloprost (Ventavis)
140
Medications for pulmonary hypertension
* Prostacyclins
* Inhaled nitric oxide
* Oral pulmonary vasodilators
141
Name a common oral pulmonary vasodilator that can be used for pulmonary hypertension.
Sildenafil (Viagra, Revatio)
142
Any problem with pulmonary arterial hypertension with Afib or AV block?
* Can reduce cardiac output
| * Should be treated
143
Why is fluid management in the setting of pulmonary arterial hypertension challenging?
* Hypovolemia results in decreased preload and cardiac output (right ventricle is preload dependent)
* Hypervolemia can exacerbate right ventricular overload (decreases left ventricular filling which decreases cardiac output)
144
How is supplemental oxygen rationalized for pulmonary arterial hypertension?
* Hypoxemic pulmonary vasoconstriction may contribute to elevated PAP
* Such vasoconstriction may result in small, but significant increase in PVR and decrease in cardiac output
145
How does pulmonary arterial hypertension appear in pulmonary artery catheter values?
* MPAP > 25 mmHg
* PCWP > 15 mmHg (indicates pulmonary venous hypertension)
* PAP elevated above 25/8 mmHg normal
* Increased PVR
146
What pulmonary arterial catheter test can be used to assess pulmonary arterial hypertension?
```
Vasodilator Response Testing (K)
Vasoreactivity test (UTD)
```
147
How is Vasoreactivity Test administered?
- -Administer a short-acting vasodilator: (iNO, epoprostenol, adenosine, iloprost)
- -Watch for MPAP to decrease by 10 mmHg and to a value <= 40mmHg (with increased/unchanged CO and minimally reduced or unchanged systemic BP)
- -Patients positive for test can get a trial of long-tem CCB therapy
- -Patients with negative test should be given alternative medication; CCBs in these patients my be harmful. (UTD)
148
How is echocardiography useful in assessing pulmonary arterial hypertension?
- -Can non-invasively estimate PAP
- -Assesses right and left ventricular function
- -Evaluates valvular disease (tricuspid and mitral)
149
Are any lab studies useful for evaluated pulmonary arterial hypertension?
BNP may be useful, but it can be elevated for other reasons
150
What imaging beyond chest film can be useful for assessing pulmonary arterial hypertension?
CT and CT angiography may be indicated for specific types of pulmonary hypertension.
151
Cases of fat embolism syndrome are most commonly associated with what problems?
Long bone or pelvic fractures.
152
Name the WHO categories of pulmonary hypertension.
1) Pulmonary arterial hypertension (idiopathic origins plus others)
2) PH 2/2 left heart disease
3) PH d/t chronic lung disease or hypoxemia
4) PH d/t pulmonary artery obstructions
5) PH d/t multifactorial mechanisms
153
What conditions give rise to group 1 pulmonary hypertension?
* Idiopathic and heritable conditions
* Drugs and toxins
* Connective tissue diseases
* HIV
* Portal hypertension
* Congenital heart disease
* Schistosomiasis
etc. !
154
Name some of the conditions that can lead to group 5 pulmonary hypertension
* Sickle cell disease
* Sarcoidosis
* CKD
155
CTEPH =
Chronic thromboembolic pulmonary hypertension
156
Left heart disease that may contribute to pulmonary hypertension (Kettering)
* Acute myocardial infarction
* Cardiac valvular disease (mitral valve stenosis or regurgitation)
* Severe diastolic dysfunction
* Cardiomyopathy
157
Pulmonary hypertension effects on the heart (Kettering)
* Increased PVR increase right ventricular afterload
* Decreased right ventricular stroke volume decreases CO
* Right ventricular end diastolic pressure increases
* Interventricular septum shift, resulting in decreased cardiac output
158
Define acute hypertension (Kettering)
A marked increase in blood pressure associated with organ damage
159
What blood pressure reading defines acute hypertension?
> 180/110 mmHg
160
Name several causal areas for acute hypertension.
* Neurologic cause (acute stroke)
* Perioperative cause (seen especially in neurosurgical and caradiovascular surgery patients)
* Cardiovascular cause (acute heart failure and chronic hypertension)
161
Medication for acute hypertension (K)
* "Nitroprusside is initial treatment"
- -rapid onset, short duration, inexpensive and efficacious
- -cyanide toxicity a potential complication
* Nitroglycerine
* Labetolol (beta blocker, commonly administered by IV)
* Esmolol (beta blocker--with duration of action only 10-20 minutes)
* Nicardipine (calcium channel blocker)
162
What is cardiac tamponade?
Pericardial effusion that causes hemodynamic compromise
163
According to UTD, what are the physical findings of cardiac tamponade?
* Beck's triad (hypotension, JVD, muffled heart sounds) --in minority of cases
* Sinus tachycardia
* Hypotension
* Elevated jugular venous pressure
* Pulsus paradoxus
* Pericardial rub (in patients with cardiac tamponade due to inflammatory pericarditis) (UTD 20200508)
164
With what modality is cardiac tamponade best evaluated?
Echocardiography can identify pericardial effusion and assess its hemodynamic significance. (UTD 20200508)
165
How does one treat cardiac tamponade?
* Aggressive fluid resuscitation
* Inotropic support with dobutamine, dopamine, isoproterenol, norepinephrine
* Percutaneous periardiocentesis is primary approach
* Pericardial window done surgically (K)
166
What is the treatment for pericardial disease?
Such anti-inflammatory drugs as--
* NSAIDs
* Indomethacin
* Ibuprofen
* Systemic corticosteroids
167
Differential diagnosis of life-threatening acute pericarditis
* Acute coronary syndrome
* Pulmonary embolism
* Aortic dissection
* Pericardial tamponade
168
One way to narrow the life-threats on the differential for life-threatening acute pericarditis--
Chest CT can rule out pulmonary embolism and aortic dissection
169
With what modality is pericardial disease best diagnosed?
Echocardiography
170
How would pericardial disease appear on CXR?
* Might appear as normal CXR
| * Might show an enlarged cardiac silhouette
171
How would pericardial disease appear on EKG?
* Would not appear on EKG
172
From where can the inflammation at the, uh, heart of pericardial disease arise?
It can be a *systemic* problem
| It can be an *isolated* problem
173
What principles should guide treatment for heart valve problems in the ICU?
* Give antibiotic prophylaxis for endocarditis
* Maintain ventilation and oxygenation
* Treat associated cardiac arrhythmias
174
How should ventilation and oxygenation be maintained for patients with heart valve problems in the ICU?
* Increase FiO2 to treat hypoxemia because fever and increased work of breathing increases oxygen demands
* Manage hypercapnea with NPPV and/or invasive ventilation
175
Name major causes of pericardial effusion.
* Acute pericarditis (viral, bacterial, tuberculosis, or idiopathic in origin)
* Autoimmune disease
* Postmyocardial infarction or cardiac surgery
* Sharp or blunt chest trauma (including cardiac interventional or diagnostic procedure)
* Malignancy (particularly metastatic spread of noncardiac primary tumors)
* Renal failure with uremia
* Myxedema
* Aortic dissection extending into pericardium
* Selected drugs
(UTD)
176
When does someone have a pericardial effusion?
When the accumulated fluid in the pericardial sac exceeds the small amount that is normally present. (UTD)
177
Name the major clinical manifestations of acute pericarditis (UTD).
* Chest pain (typically sharp and pleuritic--improved by sitting up and leaning forward)
* Pericardial friction rub (a superficial scratchy and squeaking sound best heard with the diaphragm of the stethescope over the left sternal border)
* Electrocardiogram changes (new widespread ST elevation or PR depression)
* Pericardial effusion
(UTD)
178
Name three categories of valvular heart disease in ICU patients.
* Acute onset: first episode of symptomatic disease
* Exacerbation: flare-up of pre-existing valve disease
* Concomitant: caused by other critical illness
179
Name consequences of mitral valve failure common in ICU patients.
* Decreased cardiac output with tissue hypoperfusion
* Pulmonary hypertension with pulmonary edema
* Right heart failure from severe pulmonary hypertension
180
What life-threats arise from cardiac valvular disease?
* CHF requiring immediate stabilization
* Shock
* Respiratory failure (K)
181
Describe invasive monitoring required for cardiac valvular disease.
* Peripheral arterial line: for systemic blood pressure
* Pulmonary arterial line: for cardiac filling pressures, cardiac output, mixed venous oxygen saturation, for calculation of left ventricular stroke volume, SVR, PVR
182
Per K, what tests should be ordered for cardiac valvular disease?
* EKG
* CXR (to find pulmonary hypertension, pulmonary edema, pleural effusions)
* Echocardiography (transthoracic echocardiogram (TTE) preferred; transesophageal echocardiogram (TEE) (K)
183
Name three broad categories of causation for right heart failure.
* Increased pressure load (increased PVR, afterload)
* Increased volume load (increased preload)
* Decreased contractility
184
What conditions increase RV afterload in ways that lead to right heart failure?
* Pulmonary embolism
* Pulmonary disease (hypoxic pulmonary vasoconstriction, destruction of vascular bed, interstitial lung disease, neuromuscular chest wall restriction)
* Primary pulmonary hypertension
* Left ventricular failure
* ARDS
* Positive pressure ventilation
185
Name conditions that increase preload in ways that lead to right heart failure.
* Atrial septal defect
* Ventricular septal defect
* Tricuspid valve insufficiency (K)
186
What condition could reduce contractility and lead to right heart failure?
Myocardial ischemia including hypotension and chest trauma.
187
Kettering on ventilator weaning of COPD patient.
* RSBI may not be the best indicator
* Initiate spontaneous breathing trial with pressure support
* Extubate as soon as possible to NPPV
188
Why does K say to extubate COPDers as soon as possible to NPPV?
* Decreases risk of VAP
* Has been shown to reduce ventilator length of stay
* Has been shown to reduce mortality
189
What does K say about adjusting Itime on ventilator for AECOPD?
* Increased Raw requires longer Itime
* Increased Itime may decrease Etime and lead to hyperinflation
* Ideal ITime optimizes delivery of tidal volume without air trapping
190
What does K recommend for ventilator humidification for AECOPD?
Avoid HMEs because they can increase Raw
191
When does K say antibiotics are indicated fo AECOPD?
When signs of infection are present:
—Fever and chills
—Cough productive of secretions that have changed color
—Elevated white blood cell count (>10,000/mm3)
192
What antibiotics does K have in mind for AECOPD?
* Penicillin/penicillinase (e.g. amoxicillin/clavulanate[Augmentin])
* Quinolone (levofloxacin, gatifloxacin, moxifloxacin)
* Cephalosporin with a macrolide (i.e., ceftriaxone plus clarithromycin)
193
What bugs are most likely behind AECOPD?
* Haemophilus influenzae
* Moraxella catarrhalis
* Streptococcus pneumoniae
* Pseudomonas aeruginosa
(UTD)
194
What corticosteroids does K recommend for AECOPD?
* Methylprednisolone IV
* Hydrocortisone IV
* Prednisone PO
195
What does K lead one to expect of CXR for AECOPD?
* Hyperinflation/flattened diaphragms
* Emphysematic parenchyma
* Infiltrates or air bronchograms if pneumonia is present
196
What does K say about breath sounds for AECOPD?
* Fine inspiratory crackles are common
* Expiratory or inspiratory/expiratory wheezes
* Coarse crackles from secretions or pneumonia
* Diminished breath sounds
197
What conditions may drive COPD into exacerbation?
* Upper respiratory infection (viral or bacterial)
* Aspiration
* Pneumonia
* Comorbidities (CHF, cor pulmonale, diabetes)
198
Name Kettering’s goals and non-invasive therapies for asthma exacerbation.
* Relieve hypoxemia (HFNC for SpO2 > 90%)
* Relieve airflow obstruction (beta agonists; anticholinergic ipratropium in ED)
* Reduce airway inflammation (IV steroids)
* Consider IV magnesium sulfate
* Consider heliox via NRB
* Consider antibiotics only if signs of bacterial infection are present
* Consider sedatives cautiously due to potential for respiratory depresssion
199
Describe Kettering’s approach to mechanical ventilation for asthma.
* Use larger ETT to reduce airway resistance
* Choose ventilator settings that minimize hyperinflation and avoid excessive airway pressure (overdistension)
* Choose safe Vts of 4-6 mL/kg IBW
* Set respiratory rate 12-24 bpm
* Consider permissive hypercapnea
* Use short Itime and longer expiratory time to minimize air trapping
* Monitor for dynamic hyperinflation (autopeep)
* Consider inhaled anesthetics (isoflurane or sevoflurane) with bronchodilatory effects
200
Name Kettering points for CXR with asthma exacerbation.
* Hyperinflation
* Flattened diaphragms
* Infiltrates only with infection in addition to asthma
201
Describe Kettering’s steps of breath sound development in asthma exacerbation.
* End-expiratory wheezing = mild symptoms
* Expiratory wheezing throughout = increasing asthma symptoms
* Inspiratory and expiratory wheezing = asthma crisis
* Absent breath sounds = severe exacerbation requiring intubation & ventilation.
202
How does Kettering say asthma exacerbation compromises hemodynamics?
* Increased intrathoracic pressure decreases venous return and cardiac output/blood pressure
* Pulsus paradoxus/paradoxical pulse may develop
203
Kettering: Why is hyperinflation bad in asthma exacerbation?
It compromises the force-generating capacity of the diaphragm—
Expiration is prolonged
And still end-expiratory alveolar pressure is positive
204
The three key pathologies of asthma exacerbation:
* Bronchoconstriction
* Airway inflammation
* Production of thick secretions
205
What therapies should be avoided in cardiac tamponade?
* Inotropic agents: value uncertain--in theory, dobutamine might be preferred--endogenous inotropic stimulation often maximal already
* Positive pressure ventilation: avoid if possible--positive intrathoracic pressure can further impair cardiac filling
* With cardiac arrest and pericardial effusion, external compression offers little benefit in supplementing cardiac filling (UTD 20200508)
206
What echocardiography findings accompany cardiac tamponade?
* Swinging of the heart within effusion
* Transiently reversed right atrial and right ventricular diastolic transmural pressures
* Cardiac chamber collapse
* Respiratory variation in volumes and flows
* IVC plethora
207
What is anasarca?
Edema from generalized and massive excess interstitial fluid accumulation.
208
What is neurogenic pulmonary edema?
An increase in pulmonary interstitial and alveolar fluid that is due to an acute central nervous system injury and usually develops rapidly after the injury. (UTD accessed 20200729)
209
What problems precipitate neurogenic pulmonary edema?
* Epileptic seizures
* Traumatic brain injury
* Various forms of intracranial hemorrhage (UTD accessed 20200729)
210
Define “Myelogenous”
Produced in the bone marrow. (Dorland’s accessed 20200729)
211
Myxedema on a patient's chart should raise what expectations?
* Hypoventilation with severe hypothyroidism
* Muscle weakness
* Depression of respiratory drive
* Some patients will need noninvasive or invasive ventilatory support during the initial phases of thyroid replacement (UTD accessed 20210216)
212
Cheyne-Stokes respirations is commonly associated with what co-morbidities?
* Cardiac disease
* Neurologic disease
* Sedation
* Normal sleep
* Acid-base disturbances
* Prematurity
* Altitude acclimatization (UTD accessed 202102160
213
What is thrombin?
* The activated form of factor II (prothrombin)
| * It converts fibrinogen to fibrin (D accessed 20211109)
214
How does a epidural hematoma appear on head CT?
"A biconvex or lenticular shape" because "clot pushes the dura mater away from the posterior wall of the skull" (Hess 1017)
