Random Flashcards
The accepted thresholds for therapy (based on the Brain Trauma Foundation guidelines) are to prevent prolonged elevations of the ICP higher than ____ and to maintain the cerebral perfusion pressure greater than ____
Goal is: ____ but no evidence to support lowering BP to get there
Equation for CPP?
Prevent prolonged elevations of the ICP higher than 22 mm Hg and to maintain the cerebral perfusion pressure greater than 50 mm Hg.
CPP goal of 50 to 70 mm Hg.
CPP = MAP − ICP
VZV Exposure management of HCP
- Give vaccine if they don’t have it (ideally within 3-5 days post-exposure, later is ok too)
- If can’t get vax (pregnant) or at risk for severe disease: Varicella-zoster immune globulin
- Keep HCP non-vaxxed or non immune away from patients for 8 to 21 days after exposure
Hypothermia
- K
- glucose
Rewarming
- K
- glucose
K goes intracellular-> hypoK
Low metabolism so hyperBG
K comes out-> hyperK
Glucose gets used-> hypoBG
Treatment of severe V vulnificus necrotizing fasciitis
Double coverage with ceftazidime and doxycycline is recommended
No remdez if
LFTs>10x
or crcl<30
Mycobacterium marinum is an aerobic, weakly pathogenic photochromogenic nontuberculous bacteria found in marine and brackish waters worldwide.
It typically causes:
Tx:
Nonhealing granulomatous skin infections in humans by direct inoculation.
Combination clarithromycin plus trimethoprim-sulfamethoxazole is a preferred treatment.
Characteristics of pressure support include triggering of each breath by patient effort (decrease in airway pressure), consistent inspiratory pressure among breaths, and variable duration of inspiration among breaths.
Also shows ineffective trigger asynchrony.
Graphic display of pressure vs time (top), flow vs time (middle), and volume vs time (bottom) for SIMV mode with volume control breath (arrow) on right and pressure support breath on left.
Electrical activity of the diaphragm (Edi) (bottom, light green)
The yellow bars highlight the variable duration of inspiration with pressure supported spontaneous breaths. The yellow arrows identify ineffective triggering, and the green arrow identifies diaphragmatic electrical activity.
Ventilator graphics demonstrating SIMV mode with presence of double-trigger asynchrony (closely positioned breaths 2 and 3).
Double triggering is often seen when there is a prolonged inspiratory effort exerted by the patient in the setting of a relatively brief set inspiratory time
Pseudomonas aeruginosa can cause serious infection in patients with ____ or ____.
diabetes or leukemia
In patients with____ P aeruginosa most characteristically is associated either with a water-exposed wound that secondarily develops cellulitis or with an aggressive form of otitis externa (ie, malignant otitis externa) in which the organism becomes highly invasive, often eroding through skin and into bone in the external canal and infratemporal fossa.
Diabetes
In patients with ____, granulocytopenia is usually the major predisposition to bloodstream infection with P aeruginosa.
leukemia
Ecthyma gangrenosum is the classic skin lesion encountered in patients with neutropenia with sepsis due to P aeruginosa and appears as
Hemorrhagic bullae on an erythematous base
Can also happen from other types of bacteremia but 75% are from pseudomonas
CSF profile in HSV-1 typically demonstrates:
Increased WBC count and lymphocytosis but the majority of patients also have an elevated RBC count
Rickettsia rickettsii causes Rocky Mountain spotted fever (RMSF)
- when?
- initial px?
- when does the rash start?
- charateristic labs?
- CSF: wbc and protein?
Spring and early summer
Presents with fever, nausea, vomiting, and headache.
Maculopapular rash that typically starts 48 to 96 h after fever onset.
Characteristic thrombocytopenia, leukopenia, and elevated transaminase levels
CSF WBC typically <100/μL [<0.1 × 109/L] with a higher elevation of protein (100-200 mg/dL
Weakness from neuroinvasive WNV
Acute flaccid paralysis syndrome has similarities to poliomyelitis, as the virus affects the anterior horn cells of the spinal cord.
A key feature of the weakness associated with WN virus is that it is asymmetric
Indications for early surgical treatment in infective endocarditis includes
1. valve dysfunction leading to signs or sx of heart failure
2. persistent and uncontrolled infection evidenced by persistent bacteremia and/or fever after more than 5 days of appropriate antibiotics.
3. ??
Consideration if:
1. IE caused by highly resistant or fungal organisms
2. recurrent emboli or enlarging vegetations despite appropriate antibiotic therapy
3. ???
- heart block, annular or aortic abscess, or other destructive, paravalvular lesions (eg, the patient in this case)
- large (>10 mm) vegetations, especially when large vegetations are associated with valvular regurgitation.
Some organisms (“SPICE” or “ESKAPE” organisms, including E cloacae, Citrobacter freundii, Serratia marcescens, Providencia stuartii, Pseudomonas aeruginosa, Hafnia alvei, and Morganella morganii) have inducible resistance through chromosomally encoded ampC genes.
Clinically, the risk for emergent AmpC-mediated resistance is greatest for ___
Enterobacter species, which includes Klebsiella aerogenes
Treatment with cefepime, piperacillin-tazobactam, or a carbapenem is an evidence-based recommendation by the Infectious Diseases Society of America.
ARREST trial
OHCA from VF or pulseless ventricular tachycardia (VT) and no ROSC after three shocks
Required estimated transport time less than 30 min from activation of the ECMO team, patients 18-75
Result of trial?
Improved outcomes with eCPR compared with standard ACLS in patients with out-of-hospital cardiac arrest (OHCA) and VF
Survival rates of 43% vs 7% Favorable neurologic outcomes in survivors
Acute onset fever, dry cough and progressive shortness of breath in a healthy patient with association to smoke, sandstorm, dust, or burning oil exposure
Acute eosinophilic pneumonia
Diagnosis of acute eosinophilic pneumonia
IMG?
Peripheral eosinophilia?
BAL?
Diffuse, bilateral, pulmonary opacities, and sometimes small pleural effusion more easily appreciated on CT images.
Peripheral eosinophilia is absent early in disease
BAL eosinophilia (>25% and often much higher), after exclusion of infection, vasculitis, or other known inciting factors, is highly supportive of an AEP diagnosis.
Acute eosinophilic pneumonia treatment and prognosis
AEP is treatable with corticosteroids, rapid improvement over weeks is typical, and relapse is rare. Smoking cessation should be strongly encouraged.
Fulminant form of diffuse lung injury that initially presents with fever, cough and shortness of breath
Acute Interstitial Pneumonia
Clinical course of Acute Interstitial Pneumonia
Rapid onset (1-2 weeks), diffuse lung injury-> unexplained ARDS with 50% mortality
Treatment of Acute Interstitial Pneumonia
Supportive care + steroids
Cyclophosphamide is sometimes used.
Diagnosis of AIP
Clinical syndrome of idiopathic ARDS and histologic confirmation of diffuse alveolar damage
FIrst line treatment for submassive or intermediate risk PE?
Both the American College of Chest Physicians and American College of Cardiology guidelines recommend against routine use of catheter-directed thrombolysis in patients with submassive or intermediate-risk pulmonary embolism.
Just anticoagulate
Tx of PE + SBP<90 or 40mmHg drop in SBP?
Lytics
Tx of massive PE (SBP<90 or 40 drop in BP) in patients with high risk of bleeding
Catheter-directed thrombolysis can be considered
Studies evaluating intermediate-risk PE + thrombolytics
Reduced incidence of hemodynamic decompensation with lytics but increased bleeding, especially intracranial.
Overall, the mortality rate was similar between thrombolytics and systemic anticoagulation at both 7 and 30 days.
Bleeding risk was especially high in people >75
Retained hemothorax (RH)
Hemothorax that remains “retained” in the pleural space despite drainage by catheter (either pigtail or chest tube)
Risk factor for infection (empyema) and formation of fibrothorax and trapped lung.
Management of Retained hemothorax (RH)
Guidelines recommend early (within 4 days) drainage of RH via VATS-> shorter hospital stays and greater cost savings
Alternative treatment of RH includes intrapleural fibrinolytic therapy via chest tube or pigtail catheter.
Hemothorax management: Drain unless ____
Other ways to manage?
Size is quite small (<500 mL)
Pigtails have similar complication rates to chest tube but better tolerated
Consider embolization of vessel
Failure to respond to these measures is an indication for thoracotomy.
ESBL-producing bacterial bloodstream infection (ceftriaxone non-susceptible)
MERINO trial, a multicenter, open-label, noninferiority, randomized controlled trial, compared piperacillin/tazobactam with meropenem for definitive treatment of ESBL-producing E coli and ESBL-producing Klebsiella bloodstream infections
Higher mortality rate with zosyn compared to meropenem
Lung abscess management
- which abx
- duration?
- when to consider biopsy, thora, chest tube or surgery
- Prolonged antibiotics (6 weeks - 6 months), starting with IV for 1-2 weeks
- Treat with b-lactam + lactamase inhibitor, carbapenem or clindamycin
- Consider surgical resection if no response to treatment or >6cm
- High mortality c emergent surgery
- Thoracentesis, chest tubes, and transthoracic biopsies should not be attempted, as they can contaminate the pleural space and lead to empyem
OUD managed with buprenorphine or buprenorphine-naloxone as an outpatient who present with acute critical illness
Continue outpatient regimen
Maximizing nonopioid analgesia strategies and adding short-acting opioids as needed
Consider dose reduction if maintenance dose is high (eg, >16 mg total daily dose) or if pain control is still inadequate after providing adequate doses of short-acting opioids.
Consider dose reduction in severe hepatic dysfunction
No renal adjustment, no dialysis adjustment
ARDS Network low tidal volume trial
Larger tidal volumes and higher airway pressures were associated with significantly better oxygenation and mechanics but _____
Worse mortality
Recruitment Manuvers
Result in improved oxygenation and lung mechanics but significant adverse _____ during RM. Also showed increased ______ despite better P/F
Significant adverse hemodynamic effects during RM
Increased all-cause mortality
PPI for VAP?
PPI for mortality or length of ICU stay?
Positioning patients with the head of the bed elevated to 30° to 45° is recommended
Routine gastric residual monitoring, PPI and early parenteral nutrition have not been shown to be effective in preventing VAP
Several multicenter clinical studies show that PPI does not reduce the rates of nosocomial pneumonia, mortality, or ICU length of stay.
NUTRIREA-2 study
Nutrition delivered via the enteral and parenteral routes in patients who were critically ill and being treated with mechanical ventilation and vasopressors
Similar outcomes however enteral nutrition route resulted in more mesenteric ischemia and colonic pseudo-obstruction
ARDS Network EDEN study demonstrated that trophic feeding rates for the first 6 days resulted in similar clinical outcomes as advancing enteral feeds to goal rates as soon as safely possible, with lower incidence of:
Gastrointestinal complications
NUTRIREA-3 study
Compared
- Lower calorie (6 kcal/kg/day) and lower protein administration (0.2 g/kg/day)
- Advancing to goal calorie and protein rates as soon as possible
Patients who were receiving mechanical ventilation and vasopressors during first 7 days of enteral feeding
Outcome
- Similar 90-day mortality rates
- Faster time to readiness for ICU discharge in the lower calorie and protein group
- Fewer gastrointestinal complications
Serum creatinine increase of ≥0.5 mg/dL or a relative increase of ≥25% in the 48 to 72 h after the administration of contrast material when other potential causes of AKI have been excluded
CIN
Major risk factors for CIN?
- age >70
- CKD
- concomitant use of nephrotoxic drugs
- 2 other chronic conditions
- 2 acute conditions
- diabetes and CHF
- shock and hypovolemia
Association between CIN and risk of dialysis or death
Patients who received radiocontrast had a similar need for dialysis and a similar risk of death as did the patients who did not receive radiocontrast. This finding was independent both of the type of radiocontrast and of the presence of diabetes and chronic kidney disease.
IVF or hemodialysis to prevent CIN?
No significant difference in incidence of AKI between patients who received peri-CT IVF
No benefit from attempting to remove contrast with hemodialysis
Treatment of acute chest syndrome
ACS is often precipitated by infection, so empiric antimicrobial treatment for pneumonia to cover bacteria such as Streptococcus pneumoniae and Haemophilus influenzae along with atypical bacteria (such as Mycoplasma and Chlamydia) should also be started.
Esophageal tamponade
- duration?
- management during use?
- pressure target?
Temporizing measure only to stabilize the patient for further treatments as soon as possible.
Only use for 24-48 h
Deflate every 12 h
Monitor pressure every hour
Maintain at 30-45 mm Hg (high enough to tamponade venous bleed without blocking critical perfusion)
INTUBE observational study
Evaluate incidence and nature of adverse peri-intubation events in international patients undergoing tracheal intubation in ICU, ER and ICU
Cardiovascular instability occurred in 42% of patients (SBP<65 x1 or <90 x 30 minutes, or new/increased pressors or fluid bolus)
Severe hypoxemia (SpO2 <80%) in 22% -> decreased to 10% with bag-mask ventilation
Difficult intubation (>2 attempts) in 5%
Aspiration of gastric contents in 4% (not made worse using BVM)
ESCAPE trial
RCT often cited as evidence that PAC does not change outcomes in patients with heart failure
Excluded: patients with recent inotropic therapy
Severe prospective series have reported improved outcomes, including decreased in-hospital mortality, when pulmonary artery catheters are used in patients with cardiogenic shock.
Indications:
Failure to respond to empiric inotropic therapy and uncertainty about intravascular volume status-> help with titration of diuretics and vasoactive agents to maximize cardiac output while minimizing arrhythmias and myocardial oxygen consumption.
Use of PAC to obtain complete hemodynamic data before initiation of temporary mechanical circulatory support is associated with:
Decreased mortality from all-cause cardiogenic shock.
IABP for cardiogenic shock?
Compared with no mechanical circulatory support, IABP use was not associated with a reduction in mortality
Only venoarterial extracorporeal membrane oxygenation plus IABP was associated with favorable outcomes compared with no mechanical support
Ineffective Triggering
Insufficient change in airway pressure or flow to meet the ventilator’s set parameters to trigger breath
Ineffective Triggering is caused by:
Auto-PEEP
Low respiratory drive
Weak inspiratory muscles
Partial ETT obstruction
High trigger sensitivity
Double Triggering (premature cycling)
Two or more positive pressure breaths occur in short succession with an incomplete expiration between them, resulting in large tidal volumes
AUTO-TRIGGERING (Extra triggering)
Ventilator delivers a positive-pressure breath without patient initiation or appropriate time-cycling
FLOW DYSSYNCHRONY (Target dyssynchrony)
Occurs when the set ventilator flow rate is lower than the patient’s desired flow rate.
The pressure-time graph shows concave inspiratory deflections because the patient produces increased negative inspiratory pressures to drive increased inspiratory flow
Cycle Dyssynchrony
Occurs when the duration of the ventilator-delivered breath does not match the patient’s desired breath duration
Cycle dyssynchrony occurs when the duration of the ventilator delivered breath does not match the patient’s desired breath duration.
If ventilator breath is shorter than the patient desires, the patient _____. The airway pressure curve will be _____ and _______ will occur after the ventilator breath terminates.
This can result in:
may exert continued inspiratory effort
pulled downward
reversal of expiratory flow
double triggering
Cycle dyssynchrony occurs when the duration of the ventilator delivered breath does not match the patient’s desired breath duration.
If ventilator breath is longer than the patient desires, the patient will begin _____ during a positive-pressure inspiration, producing ___ with increased expiratory flows
active expiration during a positive pressure inspiration
end-inspiratory peak pressure elevations with increased expiratory flows
Cycle dyssynchrony
Ventilator breath is longer than the patient desires so patient begins active expiration during a positive-pressure inspiration, producing end-inspiratory peak pressure elevations with increased expiratory flows
How to avoid death spiral of salicylate toxicity
One thing that can precipitate it
Watch/correct:
Intubating can precipitate because you take away their attempt to compensate
Alkalinization with bicarb to keep it in the non-toxic form that leads to absorption until salicylate level is below 40
Fluid status (usually need a good amount of resuscitation) and electrolytes (K/glucose)
Gram stain showing encapsulated gram- positive, “boxcar”- shaped bacilli
Anthrax, bacillus anthracis
