the 10 commandments Flashcards
Name 3 antibiotics for pseudomonas coverage (just the classes)
- Extended spectrum penicillin with B-lactamase inhibitors (Piperacilin-Tazobactam = antipseudo penicillin)
- Cephalosporins
- Fluoroquinolones
Additional from amboss:
- Carbapenems
- Aminoglycosides
- Monobactams
- Polymyxins
What are 5 indications for dialysis?
AEIOU:
- Acidosis(<7.1 ph or refractory to therapy)
- Electrolytes(K+ over 6.5 mmol/l)
- Intoxication
- Overloaded with fluid,
- Uremia/uremic symptoms
-hypo/hypernatremia (<115, >160)
-AKI (>350 umol/l creat, >12hr anuria)
-hyperthermia(>39.5 )
Child CPR/ALS difference from adults?
15:2 ratio.
From Amboss:
· Children older than 1 year
o 5 initial rescue breaths → CPR
o Compression rate: 100-120/min
o Compression-to-ventilation ratio:
- § Medical professionals: 15:2
- § Lay rescuers: 30:2
o Further management should follow the guidelines for adults.
· Defibrillation: monophasic and biphasic waveforms: 2–4 J/kg of body weight
Symptomatic treatment of bradycardia, top 3 pharmacological agents.
- Atropine (he asked dose, 500mcg IV each time for max 3mg)
- dopamin
- isoprenaline
- adrenaline
- glycopyrrolate
Ultrasound during CPR, you can investigate:
1 H, 3 Ts.
H
- Hypovolemia (collapsing IVC)
T
- Tamponade (Collapsed RV + fluid filled pericardium),
- PE (Enlarged RV and RA), collapsed left side
- PTX (Lack of lung sliding and B-lines).
How many joules for infants/children with the defib?
4 J/KG
Dose of Epinephrine and how do you give a patient in ICU?
Infusion, he was happy with 0.01- 0.03 mcg/KG/min
5 uses of end tidal CO2 during CPR? (capnography)
PQRST: Placement of airway device, ETT (endotracheal tube?),
Quality of compressions,
ROSC also know the values whats normal, what’s bad, and what is terminate-CPR bad.
Strategy : if <10 mmhg for long time> bad prognosis
Termination ( etCO3 >24, Rosc, spontaneous respiration)
etCO2 ROSC values
> 24
- stop ALS, check circulation ( ROSC)
20-24
- Chest Comp is effective
<20
- improve CC quality
=<10
- Poor prognosis
3 indications for systemic thrombolysis?
Early STEMI (< 12 hours) but rare
Early ischemic stroke (< 3 hours)
Massive pulmonary embolism
Acute peripheral arterial occlusion
Top nosocomial bacterias?
Klebsiella
Acinetobacter
MRSA
Pseudomonas
3 symptoms of hypoglycemia:
CNS(agitation, coordination, sleepiness)
pale,
sweating,
tachycardia
Basic difference between CRRT and IRRT? What do you use when?
CRRT= Continuous Renal Replacement Therapy, done over 24 hours, and is a slow type of dialysis
IRRT= Intermittent Renal Replacement
Therapy: performed for less than 24 hours in each 24 hour period,
two to seven times per week
CRRT has better
-haemodynamic stability (BP control)
- improved survival
- greater likelihood of renal recovery.
Name 5 opioids commonly used?
Morphine, fentanyl, sufentanyl, Remifentanil, tramadol, codeine
Name 3 non invasive airway measures?
Head chin tilt,
eschmark,
cpap bipap,
oxygen,
bag mask
4 symptoms of shock:
MOF,
Urine output<0,5ml/kg,
loss of consciousness, confused,
GI: absent bowel sounds
(adding)
Paleness
Cold-sweat
Cold skin (warm skin if distributive shock like sepsis/anaphylactic)
Lethal triad:
Coagulopathy, Hypothermia, metabolic acidosis
4 iv anesthetics
- Thiopental (= barbiturate 3-6mg/kg)
- Midazolam (= benzodiazepines 0.01-0.1 mg/kg)
- Propofol (2-4mg/kg) most popular
- Ketamine (1-5mg/kg)
3 inotropes:
- Norepinephrine
- Epinephrine
- Dobutamine
- Dopamine
Side affects of local anesthetics:
- Bradycardia and ventricular arrhythmias
- Hematoma → nerve compression→ neurological symptoms
- Infections
- Allergic reactions
- Spinal/epidural: Headache, bradycardia, hypotension…
How do you diagnose airway at risk
Listening for snoring, gurgling, choking + paradoxical movement
Criteria for empty stomach (how long do you need to fast):
Clear fluids (water, tea) = 2h
Breast milk = 4h
Nutritional drinks –cow milk – solid food = 6h
First line treatment of tpx:
Provide resp. support
Treat dyspnea
immediate tube thoracostomy
Caloric value of carbohydrates lipids protein and alcohol
- Carbohydrate (60-80% of nutrition): Glucose = 4,2Kcal/g ;
Max glucose dose of ICU patients 5mg/kg/min - Lipid (20-40% of nutrition): 9,1Kcal/g; lipid oxidation is limited, max dose = 1-1,5g/kg/day
- Protein: daily requirement in critical care =1,5-2 g/kg/day
- Alcohol: I guess 0 because the patient is in critical care ???
Formula of osmolality:
= 2[Na+] + [Glucose]/18 + [BUN]/2.8 (mg/dl)
In case: Osmolarity = 2Na + Glucose + Urea (mmol/L)
Shock definition:
Acute hemodynamic disorder (micro and macrocirculatory) independent of the cause, which
leads to insufficient oxygen supply and tissue hypoxia.
3 Application of ETCO2:
noninvasive technique which measures the partial pressure or maximal concentration of carbon
dioxide (CO2) at the end of an exhaled breath (N: 35-45 mmHg). Can be used to detect
metabolic acidosis (but ABG is the gold standard)
3 SUBLINGUAL antihypertensive drugs and their dose –
nitrates, ACEI, niflodipin.
Captopril = 25mg
Nifedipine = 10mg
Prozasin = 2mg
First choice of bradycardia treatment
Atropin
How to calculate PULMONARY MAP
= 1/3SBP + 2/3DBP
Atmospheric pressure in mmHg and mmH2O
760mmHg or 10332,276 mmH2O
5 reasons AMI can cause cardiogenic shock
- Wall rupture (late phase)
- Arrhythmia
- Valvular dysfunction (e.g papillary muscle necrosis)
- Decreased contractility (pump function)
- Wall rupture → tamponade
3 complications with Central venous catheter
Infection
Rupture of Artery
pneumothorax
4H & 4T
H:Hypoxia
H: Hypovolemia
H: Hypo/HyperKalemia
H: Hypo/hyperthermia
T: toxins
T:tamponade
T: Tension PTX
T: Thrombosis
Gynecological emergencies in ICU
Placental abruption,
miscarriage,
ectopic pregnancy,
Acute PID,
Pelvic endometriosis…
Difference between dehydration and hypovolemia
Hypovolemia is a condition where the extracellular fluid volume is reduced and it results in
decreased tissue perfusion.
It can be produced by either salt and water loss.
Dehydration: Is when there is only water loss.
Respiratory failure classes
Type I - hypoxemic failure
Type II - hypercapnic failure
Type III - post-operative failure
Type IV - CV-associated failure (shock-ass hypoperfusion)
Type 1 respiratory failure values
decreased arterial oxygen = PaO2 < 60 mmHg
(SaO2 < 90%,
PaCO2 decreased/normal,
pH increased/normal).
Type 2 respiratory failure values
increased arterial carbon dioxide = PaCO2 > 50 mmHg or pH < 7.3 (respiratory acidosis).
Anaphylactic shock symptoms (give the answer in ABCDE order)
A: Wheezing (bronchoconstriction)
B: dyspnea
C: Hypotension, Skin: hives, itching, urticaria, Angioedema
D: dizziness, fainting
E: nausea, vomiting
Define septic shock
Is a type of distributive shock caused by an excessive inflammatory response to disseminated infection,
which leads to extravasation from the vascular space and loss of intravascular volume.
3 indications of central vein
- Dialysis
- ICU
- Longer hospital stay
- Fluids
What is 60-40-20 rule
Total body water = 60% of body weight
Intracellular fluid = 40% of body weight
Extracellular fluid= 20% of body weight
Antidotes for opiates, benzodiazepine and non depolarizing muscle relaxant
- Opiates= Naloxone
- BZ= Flumazenile
- Non depolarizing muscle= Neostigmine (cholinestherase ihibitors)
3 ways to measure cardiac output
- Doppler ultrasound
- Pulse pressure methods
- Impedance cardiography
- MRI
- Calculate = SV x HR
swan ganz catheter
arterial line
Puncture in ribs
- midaxillary line: 4-5 intercostal space
or
- mid clavicular: 2 intercostal space
(just above the third rib)
for needle decompression (faster)
Parameters in mechanical ventilation
*Mode:
- Assisted control
- Intermittent mandatory ventilation
- pressure ventilation which is CPAP and BiPAP
- volume ventilation
* FiO2,
* Tidal volume and respiratory rate which will change the alveolar ventilation and positive end expiratory pressure which is the PEEP
* Flow
Horowitz index
ratio of partial pressure of oxygen in blood (PaO2), in millimeters of mercury, and the fraction of
oxygen in the inhaled air (FIO2) — the PaO2/FiO2 ratio.
→ used to assess the lung function in patients, especially those under ventilators.
Treatment protocol for tachycardia
- Beta Blockers,
- vagal maneuvers,
- cardioversion electrical or chemical
- ICD,
- PM,
- ablation
Hyperkalemia : ECG
- Peaked T waves on prechordial leads
- PR prolongation
-wide QRS - p wave flattening
Treatment for hyperkalemia?
Mention 5:
- Insulin-glucose
- Ca-gluconate I.V,
- Haemodialysis
- B-agonist (activates Na/K pump moving K into cells)
- NaHCO3- (alkalosis drives K into cell)
Indications for HCO3-:
- CPR when severe acidosis pH<7,1
- strong suspicion of metabolic acidosis,
- Correct hyperkalaemia (K+ + HCO3+), pH < 7,1
Correction of symptomatic bradycardia:
Atropine 0,5mg —> 3mg (0,5 every bolus)
Layers for spinal anesthesia
Injection site:
Injection usually performed below L2 to avoid damage to the spinal cord
Needle inserted into subarachnoid space between the arachnoid and pia mater
Layers the needle goes through:
Skin
Subcutaneous fat
Supraspinal ligament
Interspinal ligament
Ligamentum flavum
Epidural space
Dura mater
Arachnoid mater
Subarachnoid space
Epidural anesthesia layers
Can be used for acute pancreatitis → Increased blood flow to the pancreas for healing.
No parasympathetic fibers in epidural anesthesis
Injection site:
May be performed at any vertebral level (cervical, thoracic and lumbar spine)
Needle inserted into the epidural space between the ligamentum flavum and dura mater
HCO3- dosage for DKA
50mmol
3 symptoms of upper GI bleeding:
- Hematemesis
- Melena (digested blood)
- Drop of BP, lightheadedness
EtCO2 normal value?
35-45
Reversible causes of cardiac arrest: Hypoxia signs and treatment
Signs
- colour of skin
Treatment
- Ventilation with suppl. O2
Reversible causes of cardiac arrest: Hypovolaemia signs and treatment
Signs:
- Pale skin
- History
- DRE
- US findings (collapsed IVC)
Treatment:
- Volume therapy +/- transfusion (Hb <7 is transfusion indication)
Reversible causes of cardiac arrest: Hypo- / hyperkalaemia signs and treatment
Signs:
- Identified by ABG/lab
Correction:
- hypokalemia - Mg++ and K+
- hyperkalenia - Calcium-gluconate IV
Reversible causes of cardiac arrest: Hypo/hyperthermia signs and treatment
Signs
- Core temperature
Treatment
- Active warming / cooling
- Treat underlying issue
Reversible causes of cardiac arrest: Thrombosis signs and treatment
Signs:
- Chest pain
- Difference in lower limbs
- US findings
Treatment
- ACS: PCI
- PE: Fibrinolysis
Reversible causes of cardiac arrest: Tension ptx signs and treatment
Signs:
- dyspnea
- assymetric chest
- US pleural sliding sign
Treatment:
- Decompression
Reversible causes of cardiac arrest: Tamponade signs and treatment
Signs:
- US
-> RV collapse in diastole
-> RA collapse in systole
-> Pericardial effusion
Treatment:
- Pericardiac puncture
Reversible causes of cardiac arrest: Toxins signs and treatment
Signs:
- history, medical documents, enviroment
Treatment:
- Elimination
- Antidotes
ABCDE: A
- Patent airway
- Airway in-danger?
- Secretions
- Foreign object
- Snoring
- Obstructed airway
(paradoxical breathing)
ABCDE: B
- Rate (normal 12-20)
- Work of breathing (accessory muscles)?
- Symmetry of chest movement and sounds?
- SaO2 % (normal > 94%)
ABCDE: C (5p’s)
- Pulse
- P-QRS-T (rhythm)
- Electrical activity present on ECG?
- Frequency
- Narrow/wide QRS?
- Regular/irregular rhythm?
- P waves present?
- P waves followed by QRS complexes?
- Pressure
- Perfusion (peripheral circulation) - CRT
- Preload
- JVP
- Lung crackles
ABCDE: D
- Mental status
- AVPU scale (alert, voice, pain,
unresponsive) - Glasgow coma scale (GCS) < 9
- Symmetry
- Pain localizing
- Pupils
-lateralizing signs - Blood sugar
ABCDE: E
‘RUSH’ exam - Rapid US in shock
Bleeding source?
Injury?
Temperature
ABG
DRE
Drugs
Toxicities
Further anamnesis
Shockable and non-shockable rhythms
Shockable
- VF, pulseless VT
Non-shockable
- PEA, asystole
Shockable rhythms - drug protocol
First dose
- Adrenaline 1mg after 3rd shock
- Amiodarone 300mg after 3rd shock
Additional doses
- Adrenaline 1mg every 2nd shock (2-5min)
- Amiodarone 150 mg after 5th shock
Non-shockable rhythm - drug protocol
Adrenaline 1mg as soon as IV access
Additional adrenaline 1mg every 2nd cycle (3-5min)
PE - US signs
Collapsed left ventricle
Grossly enlarged right ventricle
US signs - hypovolemia
Collapsed left ventricle
Collapsed right ventricle
Collapsed IVC
Indications of ICU
and circumstances of admission:
• Indication:
1. severe life-threatening illnesses and injuries, which
2. require constant, close monitoring and support from specialist equipment
3. and medications in order to ensure normal bodily functions
• circumstances of admission:
-surgery,
-trauma
-severe illness
ICU limitation
• ICU beds are a very expensive
• and limited resource:
– specialised monitoring equipment
– a high degree of medical expertise
– constant access to highly trained nurses
• reserved for those patients with
1. reversible medical conditions +
2. who have a reasonable prospect and physiological reserve for substantial recovery
Invasive arterial pressure
monitoring
•
Indications:
– hemodinamics instability
– vasoactive therapy (both hypo and hypertension)
– Surgery of a high risk patient (perioperative monitoring)
Invasive arterial pressure advantages
Advantages:
– Continuous pressure measurement
– Accurate
– both the wave and the values can be seen
relative Contraindications of Epidural
Anesthesia
RELATIVE:
1. Hypovolemia/ shock-state
2. Severe cardiovasular disease
3. Lack of Informed consent
absolute Contraindications of Epidural
Anesthesia
- Haemophilia and/or coagulation disturbances
– Aquired/iatrogenic
– Hereditary
– Consequence of diseases (eg. DIC) - Inflammation/wound on skin
IV Anti-HTN drugs?
(3)
Labetalol
Metoprolol
Nicradipine
Hydralazin
fenoldopam (D1 agonist)
Nitroprusside (release NO)
diazoxide (K ch opener)
Muscle paralysis agents?
(3 examples)
Succinylcholine
AtraCURIum
RoCUROnium
Inhalation anesthetics?
(4 examples)
Halothane (most potent)- hepatotoxic
Isoflurane
Sevoflurane (most common, rapid onset & recovery)
Desflurane (least potent)
nitrous oxide
- induction (pediatric)
- maintenance
sedation
lower MAC ; more potent
NSAID side effects?
(3)
blurred vision
dizziness
nausea
vomiting
gastric ulcer
MAP equation
MAP = [SBP + (2*DBP)]/3
Which organs affected MOF and symptoms?
SOFA
Respiration: PaO2
Coagulation: PLT count
Liver: Bilirubin
Cardiovascular: MAP
CNS: Glasgow Coma Score
Renal: Creatinine, Urine output
SOFA > 2 ; organ dysfunction
Causes of delirium?
Advanced age
Pre-op cognitive disorder
Severe general status
Preop anemia
Preop hypoalbuminemia
BZD: midazolam
Chronic alcohol consumption
ASA Scoring?
General risk assessment
normal Lactate?
0.5 to 1.5 mmol/L
Causes of cardiogenic shock?
Pump function decrease
Valvular disorder
Arrhythmia
Intracardiac shunt
placement of intraosseous IV
tibia
humerus - 45 angle
Metabolic acidosis symptoms
increased sympathetic activity
Kussmal respiration
Hyperkalemia
Hyperventilation
Emesis
Invasive ventilation
- ETT
- Tracheostomy
- oropharyngeal
- supraglottic air device
O2 carrying capacity of blood
100 ml blood contains 15g Hb
which can bind 20.1 ml of O2
1gram Hb: 1.34 ml O2
How much oxygen can 1g Hb carry
1g Hb : 1.34 ml O2
Vessel placement CVL
IJV
Subclavian v
femoral vein
