Pretest_2_CriticalCare Flashcards
Bleeding from a tracheostomy could indicate a ______________ fistula, which has a 50% mortality rate.
Tracheoinnominate artery (trachea to right brachiocephalic artery). Inflate the tracheostomy, reintubate the patient, remove tracheostomy and place finger into site to anteriorl compress before median sternotomy
What is the “rapid shallow breathing index”?
respiratory rate to tidal volume (in L; normal tidal volume is 0.5 L)
What are the indications to attempt extubation?
- rapid shallow breathing index
- negative inspiratory force
- respiratory rate
- minute ventilation
- PEEP
- rapid shallow breathing index (RR:TV) of 60-105
- negative inspiratory force greater than -20cm H2O
- respiratory rate less than 20/min
- minute ventilation (RR times tidal volume) < 10L/min
- PEEP <5
Which inhalational anesthetic can cause progressive distension of air-filled spaces?
Nitrous oxide, which has a low solubility compared with other inhalation anesthetics. It can lead to worsened distention (which is bad for intestinal obstruction!!)
How is ARDS diagnosed?
1) bilateral pulmonary infiltrates on Xray
2) PaO2/FiO2 ratio less than 200
3) pulmonary wedge pressure less than 18 (to exclude pulmonary edema)
ARDS is marked by which 3 major physiologic alterations?
1) hypoxemia (unresponsive to increased FiO2)
2) decreased pulmonary compliance
3) decreased functional residual capacity (air in lungs following expiration)
Banked blood shifts the hemoglobin-oxygen dissociation curve to the (left/right). Why?
Left (decreasing oxygen uptake by tissues). This is because banked blood is low in 2,3-DPG (an RBC organic phosphate)
Chronic lung disease shifts the hemoglobin-oxygen dissociation curve to the (left/right). Why?
Right, enhancing oxygen uptake by the tissues. Chronic lung disease leads to chronic hypoxia, which leads to an increase in 2,3-DPG
What is the progression of dopamine’s effects by dose?
1) low
2) higher
3) highest
low ( mainly dopaminergic receptor mediated effects: increase of blood flow to kidneys
higher (2-10) –> B1 agonist effects = inotropic effect on myocardium = increased CO and BP
highest (>10) –> a receptors cause peripheral vasoconstriction, decreased kidney function, hypertension
** at all doses, DBP rises = increase in coronary blood flow
T/F: An opioid antagonist (like naloxone) will inhibit the central effects of morphine (respiratory depression,generalized pruritus), but will not affect the local pain-relieving effects.
True!
In the case of acalculous cholecystitis, what procedure should be undertaken?
percutaneous drainage of the gallbladder
In septic shock there is a(n) (increase/decrease) in CO and a(n) (increase/decrease) in peripheral resistance.
increase in CO, and decrease in peripheral resistance
How does PEEP lead to increased dead space ventilation? What are other potential negative impacts?
increased PEEP leads to decreased capillary perfusion = increased dead space ventilation
can also result in barotrauma and decreased venous return
What is the Beck traid of cardiac tamponade?
1) systemic hypotension
2) jugular venous distension
3) distant heart sounds
Define pulsus paradoxus:
decrease in SBP by more than 10 mm Hg at the end of the inspiratory phase of respiration
How does epinephrine affect the anesthetic effect of anesthesia?
It doubles the duration of infiltration anesthesia and increases the maximal safe total dose by decreasing the rate of the drug’s absorption. But DO NOT inject into areas supplied by end arteries (finger tips, penis, toes, ears).
Indirect hyperbilirubinemia and anemia are seen in (immediate/delayed) hemolytic transfusion reactions.
Delayed
Why is the urine acidotic in contraction alkalosis (by vomiting, gastric outlet obstruction, etc)?
Because there is exchange of sodium for hydrogen ions in the distal tubule to maintain volume status
A tracheoinnominante artery fistula (TIAF) is due to low placement of the tracheostomy tube (distal to the __ and __ tracheal rings). How should it be confirmed?
2nd and 3rd tracheal rings. Confirmed in the OR with bronchoscopy
A tracheostomy is placed (above/below) the cricoid cartilage, the strap muscles are (spared/divided), the thyroid isthmus is divided if necessary, and the trachea is entered at the ___ tracheal ring.
BELOW the cricoid cartilage
strap muscles are spared (retracted laterally)
second tracheal ring
Treatment of malignant hyperthermia includes cessation of the offending agent, (hyper/hypo) ventilation, administration of ______, and (acidification/alkalinization) of the urine.
HYPERventilation
administration of dantrolene
alkalinization of the urine
Acute PE causes CVP to (elevate/decrease)
Elevate – stress on RV –> stress on RA
_________ is strongly suggestive of cholesterol atheroembolization.
Eosinophilia
Addison’s disease/adrenocortical insufficiency is characterized by (hypo/hyper)natremia and (hypo/hyper)kalemia.
Hyponatremia
Hyperkalemia
Which incisions contribute to V/P mismatch?
Thoracic and upper abdominal
Patient with burns is made hyperkalemic after induction with this anesthetic agent:
succinylcholine
(this agent causes a rise in potassium in everyone due to its efflux from the skeletal muscle at the NMJ; patients with burns, trauma, severe infections, or neuromuscular disorders have a greater than normal potassium efflux)
To assess volume status and need for ongoing inotropic support, use what to monitor?
pulmonary artery catheter (post AAA repair, etc)
Which coagulation factors does prothromin time measure?
Factors II, V, VII, X, fibrinogen
The thrombin time measures which coagulation factors?
Fibrinogen
Cardiac risk is elevated when there are >__ PVCs/min, when there is dyspnea on exertion, and in _______ regurgitation (in addition to CHF, MI within 6 months, etc).
> 5 PVC’s min
dyspnea on exertion
mitral regurgitation
Why is it that massive overdose in local anesthetics might only be reflected as depressive symptoms?
Usually toxicity results in stimulation of neurons, followed by depression. In a massive overdose, all the neurons may be depressed at the same time.
What is paradoxical acidic urine?
In the contraction alkalosis accompanying gastric outlet obstruction (loss of gastric acid), potassium depletion and volume deficits provoke exchange of sodium for hydrogen ion in distal tubule with exacerabtion of metabolic alkalosis. The urine is acidic despite the alkalosis.
When is awake intubation contraindicated?
if elevated ICP is suspected or if a penetrating eye injury exists
What does the partial thromboplastin time measure?
Factors II, V, VIII, IX, X, XI, XII, fibrinogen
What is the normal PaO2/FiO2 ratio?
500
<200 = ARDS
CT imaging show multiple small intraparenchymal hemorrhages at the gray-white matter interface of the cerebral cortex, corpus callosum, or brainstem suggests
diffuse axonal injury
(most common = deceleration injury, child abuse, falls, assaults).
MRI may initially be normal
Name every point that can be awarded for the GCS
Eyes (4 possible points) open eyes spontaneously = 4 to voice = 3 to painful stimuli = 2 does not open eyes = 1
Verbal response (5 possible) normal, oriented = 5 confused/disoriented = 4 utters inappropriate words = 3 incomprehensible = 2 no sounds = 1
Motor response (6 possible) obeys commands = 6 localizes pain = 5 withdraws from pain = 4 decorticate (flexion) = 3 decerebrate (extension) = 2 no movement = 1
Which of the following is atypical for an acute abdomen: n/v following onset, writing in pain, focalized pain, sudden-onset abdominal pain, voluntary guarding?
writhing in pain (more classic of colicky pain); most acute abdomens = motionless
What is the name given to the phenomenon describing shoulder pain secondary to peritoneal fluid or air?
The Kehr sign (based on anatomic overlap of C3, C4 dermatomes in shoulder and phrenic nerve roots)
Shoulder pain following a lap cholecystectomy is more likely due to
subdiaphragmatic air (from insufflation)
Name whether the following structures are innervated by the greater, lesser, or least splanchnic nerves. Which dermatomes do they correspond to?
Esophagus through proximal duodenum (foregut)
Distal duodenum to transverse colon (midgut)
Descending colon to anus (hindgut)
foregut = greater = T5-T9 midgut = lesser = T9-T11 hindgut = least = T11-L3
What are risk factors for atypical angina (unusual presentations of MI)?
female gender, diabetes mellitus, advanced age
If you suspect a perforated duodenal ulcer, what is the next step in management?
upright AXR looking for free air
What are the stages of shock?
Stage 1: 100
Stage 3: 30-40% blood loss (1500-2000); UOP 20; tachy>120; hypovolemic shock, SBP 100 or less
Stage 4: >40% blood loss (>2000); UOP negligible, tachy>140, SBP<70, SHOCK
Blood is given with crystalloids for stage 3 and 4 shock
