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ACNP Exam > Need to know > Flashcards

Need to know Flashcards

1
Q

RA (preload) normal range & definition

A

The pressure in the RA, reflecting the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system

Normal range 2-6mmHg

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2
Q

CVP (preload) normal range and definition

A

Reflects the amount of blood returning to the heart and is often a good approximation of RA

Normal range 2-6mmHg

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3
Q

RV pressure normal range and definition

A

a direct measure that indicates RV function and general fluid status. Increased RVP may indicate pulmonary HTN, RV failure, or CHF.

This pressure can be estimated in an echocardiogram

normal range 15-30mmHg (systolic)
2-5mmHg (diastolic)

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4
Q

PA pressure normal range and definition

A

Reflects BP in pulm a. increased pulm a. pressure can indicate: a L–>R cardiac shunt, pulm a. hypertension, COPD, or emphysema, pulmonary embolus, pulmonary edema, and cardiac compression

normal range 20-30mmHg (systolic)
5-10mmHg (diastolic)
Mean 10-20mmHg

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5
Q

Pulmonary capillary wedge pressure (PCWP, PAOP, PAWP) preload normal range and definition

A

Measures the LV pressure when the mitral valve is open. High PCWP can indicate LV failure, mitral valve pathology, cardiac insufficiency, and cardiac compression (preload)

Normal range 8-12mmHg

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6
Q

Systemic vascular resistance (SVR) afterload definition and normal range

A

The measurement of resistance or impediment of the systemic vascular bed to blood flow. An increased SVR can be caused by vasoconstrictor, hypovolemia, or late septic shock. A decreased SVR can be caused by early septic shock, vasodilators, morphine, nitrates, or hypercarbia

Normal range 900-1400(dyne*sec)/cm^5

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7
Q

Cardiac output (CO) definition and normal range (contractility)

A

The volume of blood pumped by the heart in 1min. increased CO indicates high circulating volume. Decreased CO indicates a decrease in circulating volume or a decrease in the strength of ventricular contraction.

Normal range 4.8-6.4L/min

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8
Q

Cardiac index (CI) (contractility) definition and normal range

A

The amount of blood pumped by the heart, per min, per meter square of body surface area

Normal range 2.5-4.2 L/min/m^2

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9
Q

Saturation of mixed venous oxygen (SvO2) definition and normal range

A

The estimate of the amount of oxygen returning to the cardiopulm circulation. reflective of the patient’s ability to balance O2 supply and demand at the tissue level

Norma range 70-75% (60-80%)

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10
Q

ABG Normal pH

A

7.35-7.45
If increased = alkalosis state
if decreased = acidosis state

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11
Q

ABG normal PaCO2

A

35-45 mmHg
If increased = respiratory acidosis
If decreased = respiratory alkalosis

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12
Q

ABG normal HCO3-

A

22-26 mEq/L
If increased = metabolic alkalosis
If decreased = metabolic acidosis

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13
Q

Goal tidal volume (TB)

A

6-8mL/kg

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14
Q

What should you start PEEP at?

A

5

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15
Q

characteristics of hypovolemic shock + treatment

A
  • multiple organ failure d/t inadequate circulating volume
  • All cardiac pressures are less than normal except SVR (increased)
  • treatment - treat underlying cause (usually dehydration), volume replacement, transfuse PRN
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16
Q

characteristics of cardiogenic shock + treatment

A
  • inadequate tissue perfusion secondary to loss of contractile function
  • CVP, PAOP, SVR = increased
  • CO, SvO2 = decreased
  • treatment: treat underlying cause, support CO with inotropic agent, support O2
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17
Q

three types of distributive shock + Characteristics

A
  1. septic shock
  2. anaphylactic shock
  3. neurogenic shock
  • systemic event –> loss of moral smooth muscle vascular response –> direct vasodilating effect
  • all cardiac pressures are below normal values
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18
Q

Anaphylactic shock treatment

A
  • volume replacement
  • epinephrine
  • glucocorticoids
  • antihistamine (prn)
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19
Q

neurogenic shock treatment

A
  • volume replacement + alpha agonists
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20
Q

obstructive shock characteristics + treatment

A
  • obstructed ventricular filling or filling of the great vessels –> inability to produce adequate CO
  • CVP, SVR = increased
  • PAOP, CO, SvO2 = decreased
  • treatment: volume replacement then relieve obstruction
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21
Q

Septic shock characteristics + management

A
  • dysreglated response to infection –> severe vasodilation + decreased tissue perfusion –> organ dysfunction
  • w/in 3 hours - measure lactate, blood cultures, broad-spectrum abx, 30mL/kg crystalloid for hypoT or lactate >/= 4
  • w/in 6 hrs - vasopressors (levofed or dopamine) to maintain MAP >/=65, reassess volume status, re-measure lactate if initial lactate was elevated
  • goals of treatment - CVP 8-12, MAP >/= 65, urine output >/= 0.5mL/kg/hr, ScvO2 > 70%
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22
Q

Normal ranges for ABG

A

pH 7.35-7.45
PaCO2 35-45 mmHg
HCO3 22-26 mEq/L

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23
Q

Rule of 9s

A
  • Head and neck 9%
  • upper limbs 9% each
  • trunk 36%
  • genitalia 1%
  • lower limbs 18% each
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24
Q

Mechanical vent settings

A
  • RR 4-20 depending on reason for intubation
  • TV (volume delivered w/ each breath) 5-8
  • FiO2 21-100% maintain PaO2 of at least 60mmHg
  • I:E ration 1:2 or 1-1.5 (incr for COPD pt)
  • PEEP (alveolar pressure) 5
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25
Diagnostic criteria for diabetes
- A1C >/= 6.5 with repeat A1C recommended in asymptomatic adults with glucose /=200 - plasma glucose - fasting glucose >/= 126mg/dL on 2 occasions - random glucose >/-200 with symptoms - oral glucose tolerance test - 2h plasma glucose >/= 200 after 75g glucose load
26
Treatment for type 1 DM
- insulin replacement - basal insulin supplemented with premeal short or ultra-short acting insulin
27
Treatment for type 2 DM
- weight loss in obese pts - oral therapy - metformin or thiazolidinediones - stimulate beta cells with sulfonylureas or non-sulfonylurea insulin secretagogues
28
Targets for glycemic control
- A1C < 6 or <7 (ADA Goal)
29
Metformin -- why do you use it, MOA, and side effects
- First-line med unless contraindicated for type 2 DM - Use - A1C reduction - Insulin sensitizer, no hypoglycemic risk when used solo - Risk for lactic acidosis, it B12 deficiency - stop using 48h before using contrast dye - contraindicated in decreased renal blood flow
30
Thiazolidinedione (TZD glitazones) - why do you use it, MOA, side effects
- pioglitazone or rosiglitazone - A1C reduction - insulin sensitizer, no risk for hypoglycemia - risk of edema, hepatic toxicity (monitor ALT periodically) - DO NOT USE IN HEART FAILURE (there is not glitz or glam with HF)
31
Sulfonylurea -- why do you use it, MOA, side effects
- Glipizide, glyburide, glimepiride - A1C reduction (often considered in addition to metformin) - increases insulin release, HYPOGLYCEMIA RISK (major cause esp if NPO)
32
Dipeptidyl peptidase-4 (DPP-4) inhibitor -- why do you use it, MOA, side effects
- sitagliptin, saxagliptin, linagliptin, alogliptin - A1C reduction - increases insulin release, largely acts on postprandial blood glucose, minimal hypoglycemia risk - risk of pancreatitis, unexplained joint aches
33
GLP-1 agonist
- Exenatide, liraglutide, albiglutide - A1C reduction - increases insulin release, postprandial, ,minimal hypoglycemia risk - slows gastric emptying, can contribute to weight loss - risk of pancreatitis, N/V - DO NOT USE IN GASTROPARESIS
34
Sodium glucose cotransporter - 2 (SGLT2) inhibitor
- canagliflozin, dapagliflozin, empagliflozin - A1C reduction - increases amt of glucose excreted in urine, postprandial, hypoglycemia risk - risk of genital mycotic infection, UTI, increased urination - FDA advisory about DKA and urosepsis risk
35
Short-acting, rapid onset insulin -- Lispro (Humalog) -- onset, peak, duration
- onset 15-30min (give within 15min or right after meals) - peak 30min-2.5hrs - duration 3-6.5 hours
36
Short-acting, rapid onset -- Aspart (NovoLog) -- onset, peak, duration
- onset 10-20min (give 5-10min before meals) - peak 1-3 hrs - duration 3-5 hrs
37
Short-acting, rapid onset -- Insulin glulisine (Apidra) -- onset, peak, duration
- onset 10-15min (give w/in 15min or right after meals) - peak 1-1.5 hrs - duration 3.5 hrs
38
Short-acting regular insulin (Humulin, Novolin) -- onset, peak, duration
- onset 30min - 1h (give 30min before meal) - peak 2-3 hrs - duration 4-6hrs
39
Intermediate-acting (NPH) -- onset, peak, duration
- onset 1-2 hrs - peak 6-14hrs - duration 16-24hrs
40
Long-acting (insulin glargine (Lantus)) -- onset, peak, duration
- onset 1h after injection - peak none - duration >/= 24h
41
Long-acting (insulin detemir (Levemir)) -- onset, peak, duration
- onset 1-2 h - peak 6-8 h - duration is dose-dependent 12h at 0.2 units/kg, 20h at 0.4 units/kg
42
Converting IV to SC Insulin
- wait until the patient can tolerate solid food - continue IV insulin for 2-4hrs after the first SC dose is given - Do not switch to oral agents from IV insulin in type 2 diabetics
43
DKA patho, symptoms, and treatment (typically type 1 diabetes)
- patho: ketoacidosis - symptoms: polyuria, polydipsia, dehydration, N/V, abdominal pain, ileus, Kussmaul's respirations, changes in mental status - treatment: isotonic fluid replacement (10-14mL/kg/hr) after 1L bolus, 10 units regular insulin followed by IV drip (0.1 unit/kg/h) until anion gap is normal. If anion gap is high and glucose is >/=250 add dextrose to fluids. treat precipitating event
44
How to calculate anion gap
([Na] + [K]) - ([Cl] + [HCO3]) > 11 = + anion gap
45
Hyperosmolar nonketotic state (HNS) - typically type 2 diabetes symptoms and treatment
- patho: without ketoacidosis --> osmotic diuresis + volume depletion + electrolyte disturbance symptoms: dehydration, glucose > 600, increased serum osmolality - treatment: isotonic fluid replacement, followed by .45% normal saline, treat electrolyte abnormalities, 10 units regular insulin by IV (0.5-0.1 unit/kg/hr), treat precipitating event
46
General s/s of hypothyroidism
- thick, dry skin - hyporeflexia - slow thought processing - small weight gain, largely fluid - constipation - menorrhagia - easily cold
47
Hashimoto's thyroiditis
autoimmune destruction of the thyroid with lymphatic infiltration. occurs after a period of hyperthyroidism -- hypothyroidism
48
Post-radioactive iodine treatment/surgical removal leads to hypothyroidism
typically results s/p Grave's disease treatment, or thyroid cancer treatment
49
Pituitary or hypothalamic dysfunction
typically see decrease in T4 and normal/decreased/slightly elevated TSH
50
Myxedema crisis s/s and treatment
- hypothermia, hypotension, hypoventilation, changes in mental status (coma), hyponatremia, hypoglycemia - typically results from infection, major cardiopulm disease, or major neuro disease - treatment - 5-8mcg/kg T4 IV initially then 50-100 mcg IV daily
51
Acute care focused diagnosis and treatment for hypothyroidism
- Diagnosis - decreased T4, increased TSH - Treatment - Levothyroxine 1.5-1.7mcg/kg/day. Need to increase dose in pregnancy Follow up TSH in 4-6 weeks and titrate to euthyroidism
52
General s/s for hyperthyroidism
skin - smooth, silky reflexes - hyperreflexia mentation - mind racing weight loss frequent, low volume, loose stool oligomenorrhea heat intolerance (always warm)
53
Common etiologies for hyperthyroidism
Grave's disease thyroiditis toxic adenomas TSH secreting pituitary tumor select meds - amiodarone, interferon
54
Grave's Disease s/s and treatment
autoimmune, multisystem presentation including exophthalmos, tachycardia, proximal muscle weakness, and goiter Treatment - antithyroid drugs (methimazole or radioactive iodine) or surgical removal
55
Thyroid storm s/s and treatment
delirium, systolic hypertension (wide pulse pressure and decreased MAP), hyperthermia treatment - beta blocker, PTU or methimazole, iopanoic or iodine, consider steroids
56
How do you calculate pulse pressure? what does the number tell you
systolic - diastolic = pulse pressure >40-60 = widend pulse pressure
57
Treatment for hyperthyroidism
beta-blocker (propranolol preferred)
58
Adrenal cortex hormones
cortisol aldosterone androgens
59
Adrenal medulla hormones
Epinephrine Norepinephine Dopamine
60
Adrenal cortex disorders
Cushing's syndrome Addison's disease
61
Cushing's syndrome
Excess cortisol typically caused by pituitary adenoma s/s - central obesity, round faces, purple striae, hypertension, hirsutism, poor wound healing Diagnostic eval - dexamethasone suppression test (give 1mg of dexa at 11pm, measure serum cortisol at 8am) Treatment - remove source of excess, manage consequence (hypoT, hypokalemia, hyperglycemia)
62
Addison's disease
Decreased cortisol production Primary - damage to the adrenal cortex Secondary - pituitary failure to release ACTH (sudden withdrawal of corticosteroids) s/s - weakness, orthostatic hypoT Diagnostic eval - Cosyntropin (ACTH) stimulation test
63
Treatment for acute adrenal insufficiency
Volume resuscitation with NSS Dexamethasone 2-4mg IV Q6H + fludrocortisone 50mcg IV daily prior to ACTH stimulation test, then hydrocortisone 50-100 mg IV q 6-8hrs
64
Treatment for chronic adrenal insufficiency
hydrocortisone 20-30mg PO daily prednisone 15mg AM, 10mg PM dexamethasone 4mg IM prefilled for emergencies
65
Adrenal medulla disorders
pheochromocytoma
66
Pheochromocytoma
benign hormone-producing tumor of the adrenal medulla causing excess release of catecholamines
67
Signs and symptoms of pheochromocytoma
5Ps pressure (persistent hypertension) pain (headache) palpitations (tachy + tremors) perspiration (profuse with flushing) pallor (secondary to vasoconstriction)
68
Lab abnormalities for pheochromocytoma
increased urinary metanephrines increased urinary vanillylmandelic acid
69
Treatment for pheochromocytoma
control CV status w/ alpha blockers followed by beta blockers until tumor removal preoperative volume expansion to prevent post op hypotension
70
Disorders of ADH
Diabetes insipidus syndrome of inappropriate AHD (SIADH)
71
Diabetes insipidus
insufficient ADH or decreased sensitivity to ADH Central - c/b damage to pit gland Nephrogenic - kidney doesn't respond to ADH Plasma free water depletion --> serum hypernatremia + serum hyperosmolality. Opposite for urine treatment - fluid replacement, maybe replace ADH

ACNP Exam (6 decks)

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