Shock

Question 1

What vasopressors are best for cardiogenic shock or right heart failure?
which one should you not use?

Answer 1

DON’T USE NEOSYNEPHRINE - neo is just alpha so gonna make it harder for heart to pump
- vaso, epi, and dobuatamine - may need levo with the dobutamine afterload reduction
- vaso good in RV failure in true PAH because it helps with perfusion of pulmonary vasculature
- milrinone ok just need to watch the kidney function. Also if it’s not left heart failure it can cause a lot more vasodilation and hypotension (cruz)

Question 2

When do you think about starting vasopressin and stress dosed steroids?

Answer 2

Often when they’re on around 20 of levo and still in shock then add vaso and stress dose steroids

Question 3

What pressor might you use in someone in septic shock but with afib with RVR and HR in the 120s?

Answer 3

Often can use neosynephrine (but remember not to use in cardiogenic shock)

Question 4

How much tPa do you give for acute PE?

Answer 4

50 mg bolus push then 50 mg over two hours

Question 5

When do you restart heparin gtt after you push tPa?

Answer 5

After PTT is <1.5x the ULN

Question 6

What does diastolic inversion of the right atrium mean? What sign is this?

Answer 6

you see this in cardiac tamponade

Question 7

What do you see in acute PE?

Answer 7

McConnel’s sign - right ventricular free wall akinesis with sparing of the apex - so the apex looks like a trampoline

Question 8

If someone is in cardiac tamponade, how much fluid do you want to pull off?

Answer 8

Even if you pull off like 50cc, that might be enough for them to stabilize

Question 9

What are the causes of obstructive shock?

Answer 9

PE, Pulmonary hypertension, tension pneumothorax, cardiac tamponade, autopeep, abdominal compartment syndrome

Question 10

What do you need to get done when you start MTP for GI bleed?

Answer 10

Probably call GI, get a CTA, may have to call IR or surgery

Question 11

What should you do if they’re in septic shock and you don’t know where it’s coming from?

Answer 11

scan their whole body according to varner

Question 12

What do you want on hand if you are intubating someone in anaphylactic shock?

Answer 12

A Frova tube - slim like the bougie but you can bag through it.

Question 13

How do you use the Frova tube?

Answer 13

Pre-load the ET tube on the Frova, put lube on the end of the frova
- if there’s resistance, don’t force it. Rotate it and advance gently
- then you remove the stiffening stylet and continue to advance no more than 10 cm, depends on size of patient

Question 14

What are the causes of distributive shock?

Answer 14

1. adrenal insufficiency
2. anaphylaxis
3. neurogenic
4. sepsis

Question 15

If you do a cosyntropin stimulation test on someone with likely adrenal insufficiency, what should their cortisol go to?

Answer 15

It should go above 20-25

Question 16

How high can a lasix drip go?

Answer 16

40 mg/h per Prisma attending but 20 mg/h per uptodate
might want to add metolazone or a thiazide like diuril

Question 17

how much glucagon do you give beta blocker toxicity?

Answer 17

3-10 mg bolus (usually 5 mg)
- then if you get response can give glucagon gtt (but may cause vomiting)
- can give dopamine - the one time to use dopamine
- can try atropine

Question 18

What is shock index?

Answer 18

HR/SBP = 0.8 - 1 is normal
>.8 means they might crash with intubation
>1 is high shock index

Question 19

What findings favor a lower GI bleed?
What’s your algorhythm of action?

Answer 19

1. hx of lower GIB - age >50yo - clots per rectum
2. suspect lower GIB or endo not available then Place NG tube and lavage
3. neg lavage or unable to place
4. Is patient actively exsanguinating? Yes - IR
   No - order CTA abd/pelvis
5. No source? - if no active critical bleed, can go with GI in am
6. Source? go to IR

Question 20

What favors an upper GIB and whats your step process of action?

Answer 20

1. history of upper GIB - age <50 - central abd discomfort - BUN/Cr > 30 - cirrhosis
2. suspect upper GIB, place NG tube, call endo, they need upper endoscopy!
3. If GI can’t identify source, call IR

Question 21

how much protamine do you use for heparin reversal?

Answer 21

1 mg/ 100 U heparin for up to 2 hours after heparin
then .5 mg per 100U heparin for like another 2 hours
then .25 mg per 100 U

up to 50 mg at a time

Question 22

What MAP goal do you want in a GI bleed?

Answer 22

60

Question 23

What do you want to setup when intubating a patient with hematemesis?

Answer 23

• Multiple suctions - can put one in the esophagus - or you can put ETT in the esophagus and blow up the balloon
• glidescope - have direct ready because getting blood on the scope may obstruct your airway

Question 24

What is your anatomy for femoral central line placement?

Answer 24

medial to lateral - vein, artery, nerve - so vein is medial to the artery
- so feel for artery and then could go 1cm medial if no US

Question 25

What is the reversal agent for warfarin?
How long does it take to work?
How long do the others last?

Answer 25

Vitamin K (5-10mg IV) and Prothrombin complex (kcentra) or FFP
- vitamin K is going to take 60-12 hours
- Kcentra and FFP will only last about 8 hours

Question 26

How do you reverse Xa inhibitors?
What are the Xa inhibitors?

Answer 26

rivaroxaban, apixaban, fondaparinux
- if it’s been less than two hours since they took it, can give activated charcoal
- otherwise, Kcentra (2000 units or 25-50 units/kg)
- andexanet alfa - there’s a high dose and a low dose

Question 27

How do you reverse dabigatran?

Answer 27

praxaban - 5g ( yes, grams)

Question 28

How can you try to reverse tPa?

Answer 28

• Tranexamic acid - 1gram loading dose and another gram over an hour
• cryoprecipitate - 10 units

Question 29

When is it actually useful to give cryoprecipitate?
How much do you give?

Answer 29

For tPa reversal - give 10 units

Question 30

Why and when do you want to give Ca is MTP?
How much and what kind?

Answer 30

• because Ca will chelate the citrate, which can lead to coagulopathy
• give after one round of MTP - give CaCl 1-2g or 3-6g Cagluconate

Question 31

What are some goals to be able to stop MTP?

Answer 31

• obs bleeding stopped and shock resolved
• platelets >50K
• fibrinogen >100-200
• INR <2 (not helpful in cirrhotics)

Question 32

Who should you call if the patient has recurrent GI bleed?

Answer 32

whoever worked on them - see if GI wants to scope them again if they’re the ones that placed clips

Question 33

What do you do if someone comes in with esophageal bleed and has banding but the banding fails?

Answer 33

consult IR

Question 34

Who do you call for bleeding gastric varices?
What about bleeding esophageal varices?

Answer 34

• gastric: IR - will do balloon occluding retrograde transvenous obliteration of the gastric varices - can also potentially do TIPS.
• esophageal: GI

Question 35

What is the specific management of hematochezia and likely lower GIB

Answer 35

• CTA to visualize where the bleed is - colonoscopy not gonna be helpful -> if bleeding sent to IR
  (RBC scan is useless and is gonna take too long)

Question 36

What bipap settings might you do for acute status asthmaticus?

Answer 36

10 PS over 6 PEEP
ketamine gtt
can give precedex if needed, opioids

Question 37

How is intubation different for status asthmaticus?

Answer 37

• want biggest ETT possible - 8.5-9 if you can (need at least an 8 for a bronch)
• use ketamine - 2mg/kg - make sure you paralyze as well - an you’ll need propofol (ketamine not enough to sedate I guess)
• if they need pressor, epinephrine will help reduce potential bronchospasm
• can try using heliox

Question 38

What are the vent settings for status asthmaticus?

Answer 38

• they’re gonna be kinda acidotic, don’t jack up respiratory rate - so RR around 12-14
• tend to use volume control - try to keep inspiratory pressure < 35
• I-time should be about 1
• they shouldn’t require a lot of FiO2
• minute ventilation should be 4-6L per minute
• can try using heliox