Surgical Critical Care

Question 1

How do you treat malignant hyperthermia?

Answer 1

Dantrolene 2.5 mg/kg

Question 2

What is the initial sepsis response

Answer 2

30 mL/kg LR, blood cultures, lactate, broad spectrum IV antibiotics, Source Control

Question 3

How do you use random cortisol in sepsis

Answer 3

If <12, start hydrocortisone 100 mg q8H

Question 4

What do you do for persistent bacteremia

Answer 4

Check TEE

Question 5

ARDS

Answer 5

ARDSnet protocol: 6mL/kg of IBW w plateau pressure <30. If severe, prone 18 hours on 6 hours off. If worsening, maximize sedation to RAAS goal of -5, paralyze, APRV
High pressure @ 20 for 4 sec, low pressure @ 0 for 0.4 sec. VV ECMO

Question 6

Indication for ECMO

Answer 6

Hypoxemia w P:F<80 despite high PEEP
Uncompensated hypercapnia w pH< 7.15
end insp plateau pressure > 35

Absolute CI: inability to anticoagulate

Question 7

How do you measure bladder pressure

Answer 7

Put pressure transducer on foley, instill 25 cc (1ml/kg for peds), zero transducer at midax line at iliac crest, measure end expiration
>12 is abd htn
>20 w organ dysfunction is acs

False elevation w bph, obese, pelvic fx

Question 8

Algorithm for abd compartment syndrome

Answer 8

Bladder pressure (instill 30 mL or 1mL/kg in peds)
>12: intraabd HTN
>20 + organ dysfunction: ACS
Bladder pressures falsely elevated by obesity, pelvic fx, BPH

If peritonitis or bowel ischemia goto OR
Stop tube, decompress w ngt, stop tube feeds
Sedate, paralyze, paracentesis if needed

Question 9

TBI Algorithm

Answer 9

elevate head, NGT, Foley, Keppra, Sodium 145-150, PPI, enteric feed/avoid hypoglycemia

Evidence of icreased ICP: Mannitol (0.5 mg/kg) if stable, hypertonic Na if unstable
Short course hyperventilation for CO2 of 32
Paralytic or barbituate
EVD/craniectomy

Question 10

What’s reversal agent for dabigatran?

Answer 10

Idarucizumab (Praxbind)

Question 11

Response to AKI/ESRD

Answer 11

Check foley
FeNA/FeUREA
Stop nephrotoxic meds, change LWMH to heparin
Start dialysis.

Question 12

Hypothermia

Answer 12

remove wet clothes, warm room, bear hugger, infuse warm saline
Irrigate with 42 degree fluids
Last resort VV ECMO

Question 13

Brain death exam

Answer 13

Rule out metabolic/iatrogenic causes of AMS:
Temperature, BP.
2 providers perform neurologic exam + apnea test
Neuro: response to stimuili, pupil exam, corneal/oculocephalic/osculovestibular/gag.

Preoxygenate, normalize CO2, place 8L/min O2 in ET tube -> disconnect from vent for 10 minutes -> if CO2>60 or CO2↑20 then +for apnea. If BP <90, patient desat (<85%), or spontaneously breathing then –apnea

Confirmatory: EEG (electrical silence), MRA (no blood flow to brain), apnea test

Question 14

How do you treat anaphylactic shock?

Answer 14

Stop all infusion and resuscitate w fluids.
100 mcg of 1:10,000 epinephrine. If ineffective double dose and/or start infusion
Consider diphenhydramine and steroids