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critical care > week 2 status epi, acute stroke, ACLS, Sepsis, pain/agitation/sedation/delirium > Flashcards

week 2 status epi, acute stroke, ACLS, Sepsis, pain/agitation/sedation/delirium Flashcards

1
Q

step plan for analgesia

A
  • give boluses or infusion of opioids
  • prn opioids (PCA)
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2
Q

step pain for sedation

A
  • when agitation not controlled by opioids
  • propofol, presadex, ketamine
  • prn boluses of benzos
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3
Q

step by plan for delirium

A
  • screen + identify early
  • non-pharm interventions
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4
Q

scales for analgesia

A

CPOT goal <2
BPS goal <5

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5
Q

opioid options for analgesia and clinical pearls , ae

A

1st line - fentanyl; hepatic metabolism, CYP3A4, tachyphylaxis (tolerance), avoid continous drip
2nd line - hydromorphone; good for renal impair, option for fentanyl tolerance, PCA available
3rd line- morphine; accumulates in renal impair, se- hypotension, bronchospasm, urticaria
Hyperanalgesia: pain threshold is decreased, nerve dysfunction

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6
Q

non-opioid options for analgesia; clinical pearls

A
  • APAP ( avoid in liver failure)
  • NSAIDS (avoid in kidney injury, risk of GI bleeds)
  • Methadone; slow titrate to avoid QT prolongation
  • Gabapentin; takes days to show effect
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7
Q

Modifiable risk factors for delirium

A
  • benzo use
  • blood transfusions - only when hgb <7
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8
Q

Non-Modifiable risk factors for delirium

A
  • age, dementia, prior coma, pre-icu emergency surgery/trauma
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9
Q

scale for delirium

A

ICDSC score<4

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10
Q

Non-pharm interventions for delirium

A

re-orient pt
use hearing aids/glasses
limit noise and light at bedtime
encourage norm sleep wake cycle
early mobilization
family presence
music therapy
limit use of benzo & anticholingerics

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11
Q

Agents for delirium

A

*only treatment not prevention
- 1st line: presadex
-opioids
- melantoin
- antipsych

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12
Q

sedation scales

A

RASS -2 light sedation
SAS 3-4

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13
Q

sedation agents- propofol

A

NO analgesic properties
fast on fast off
highly lipid soluble cautious in obese pts
ae: resp depression**intubation, hypotension, bradycardia, PRIS (propofol related inf syndrome)
lipid soluble, nutritional value
egg, sulfites and soybean allergies
first line w/ severe alcohol w.drawal and SE

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14
Q

sedation agents- Precedex

A

a2 adregenic agonist
do not use >24hrs
sedative AND analgesia effects
ae- bradycardia + hypotension
no resp depression, similar to natural sleep, opioid sparing, adj for severe EtOH w/drawal
not for sleep depression
risk of w/drawal add clonidine

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15
Q

sedation agents- benzos

A

great short term, prolonged use inc AE
- Midazolam (shortest duration), accumulates, lipophilic, 1st primary SE
- Lorazepam AE: propylene glycol acidosis (high anion gap), can use renal/hepatic failure
- Diazepam longggg half life 2-3.5 days
- risk of delirium, inc time on vent, inc length of ICU stay

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16
Q

sedation agents- ketamine

A

Multi-Moa for aggitation, pain, antidep, bronchodilator
fast on fast off
no resp dep
ae: emergence rxn (elderly w/ dementia and schizo *pretreat), oral secretion, tachycardia, HTN

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17
Q

neuromuscular blockers monitoring

A

2 twitches is goal, >2 means not enough sedation, <2 means too much

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18
Q

NMB indications

A

facilitate mech vent
dec o2 consumption (resp distress)
inc muscle activity
inc intracranial or abdominal pressure
surgical procedures
rapid sequence tubation

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19
Q

NMB drugs and pros/cons

A

Ciatracurium, Rocuronium, Vecurium, Succinylcholine
- Pros: dec diaphragm activity, dec chest wall rigidity, eliminates work of breathing
- Cons: pt cant communicate, no analgesic or sedative properties, risk of DVT and skin breakdown, corneal abrasion risk, critical illness polyneuropathy

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20
Q

identifying sepsis 2 criterias

A

-qsofa at least 2: sbp<100, rr>22, ams
SIRS at least 2: temp >38 or <36, HR>90, RR>20, WBC >12E9 or <4E9

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21
Q

sepsis 1st hr Bundle

A
  • measure lactate
  • obtain blood culture
  • admin broad spectrum abx
  • rapid admin of crystalloids 30 ml/kg ( for hypotension or lactate >=4
  • admin vasopressors a/f fluids to maintain map >65
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22
Q

abx timing for sepsis

A

if shock and/or sepsis is present, give abx immediately within first hour,
if shock is absent and sepsis is possible give abx within 3 hour

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23
Q

when to give MRSA coverage

A

hx of MRSA
recent IV abx
hx of reoccurring skin inf/wounds
presence of invasive devices
recent hosp admin
severity of illness

24
Q

when to give multi-drug resistant coverage and regimen

A

proven inf w/ resistant org w/in 1 yr
recent broad spec IV abx w/in 90 dys
travel to endemic country in 90days
local resistant org
hospital acquired inf
- 2 gram ned emperic coverage agents

25
Q

what is refractory shock and how to treat

A

poor response to fluids + vasopressors
- high dose corticosteroids or NE +/- vasopressin

26
Q

which cardiac rhythms are shockable vs non-shockable

A

shock: VF, pVT
non-shockable: PEA, Asystole

27
Q

what drugs can be admin endotrachaeal route and conversion

A

2-2.5: 1 IV/IO
NAVEL drugs; naloxone, atropine, vasopressin, epinephrine, lidocane
dilute w/ 5-10 ml sterile H2O or NS

28
Q

role of epi in ACLS and when to use, dose

A
  • inc organ perfusion by inc coronary and cerebral pressure
  • admin ASAP in PEA/Asystole , admin after 2 shocks in VF/pVT
  • 1mg IV/IO q3-5 mins
29
Q

Antiarrhytmics AC;S

A
  • admin after 3 shocks in VF, pVT
  • lidocaine (do not use with norm QT interval)
  • amiodarone (bradycardia, hypotension, qt prolongation)
30
Q

6Hs (reversible causes) of ACLS and treatment)

A

Hypovolemia (fluids)
Hypoxia (100% o2 mask)
Hydrogen ion acidosis (bicarb)
Hyperkalemia (Bicarb, insulin, dextrose, diuresis, dialysis)
Hypothermia
Hypoglycemia

31
Q

5Ts (reversible causes) of ACLS and treatment)

A

Tension pheumothorax (needle decompress)
Tamponade (needle to drain)
Toxins (naloxone-opioids, lipid emulsion-anesthesia, bicarb-antidepress)
Thrombosis ( pulmonary-alteplase, coronary- tenecteplase & PCI)

32
Q

provoked causes for seizures

A

intoxification
w/drawal
trauma
meningitis
psychiatric
metabolic derangements

33
Q

first line agent to stop active seizures

A

benzos; lorazepam 4mg> diazepam 5-20mg, midazolam max 10mg
- impaired consciousness, resp depression, hypotension
- give during first 10 mins

34
Q

agents to prevent seizures

A

antiepileptics- phenytoin, leviteracetam, valporic acid, lacosamide

35
Q

how to treat super refractory status epi

A

ketamine inf
load 1.5-3 mg/kg iv once
MainD 0.1-4 mg/kg/hr max 15mg/kg/hr

36
Q

how to treat refractory status epi

A

High dose benzos
-Midazolam bolus/inf
- Propofol IV inf (only use if pt intubated)
- Phenobarb or pentobarb (only use if pt intubated)

37
Q

goal of therapy for status epi and monitoring

A

burst suppression for 24-48 hrs
slow titration while monitoring LTM Midazolam should be titrated off early because it accumulates in fatty tissue

38
Q

post intubation treatment (seizures)

A

paralytic for intubation
iv inf of antiepi (propofol or midazolam)
long term EEG monitoring
2-3 IV antiepi + 1 continous IV inf

39
Q

what is refractory SE

A

no response to anticonvulsants; seizures lasting >2 hr OR recurring 2 or more episodes per hour w/o recovery to baseline despite treatment

40
Q

phenyotin conct calculations

A

norm= (cp obs)/(.275x albumin) +0.1
poor renal norm= (cp obs)/(.1x albumin) +0.1

41
Q

Phenytoin AEs

A

p450 interactions
Hirsutism/hypertrichosis
Enlarged hums
Nystagmus
Yellow-browning skin (hepatitis)
Teratogenicity
Osteomalacia (Vit D deficiency)
Interference w/ folate metabolism (anemia)
Neuropathies (vertigo, ataxia, headache)
SJS, Rash fever, neutropenia, thrombocytopenia

42
Q

phenytoin dose, metabolism and risk

A
  • LD 20mg/kg IV, MD 4-6mg/kg/day
  • highly protein bound
  • CV: hypotension, bradycardia, QT prolongation **slow titration to mitigate
43
Q

phenytoin monitoring

A

10-20 for total phenytoin
correct low albumin (if albumin <3.5 more free drug available, leads to toxicity)
adj for kidney function (crcl <30)

44
Q

Leviteracetam dose, AE

A

LD 60mg/kg max 4500 mg, MD 1000 mg IV BID
AE- agitation and drowsiness

45
Q

Valporic Acid dose, monitor, AE

A

LD 40mg/kg max 3000, MD 5mg/kg IV Q8H
- goal level 50-100
- AE: thrombocytopenia, Hyperammonemia > pancreatitis (peds), HA, drowsiness

46
Q

Lacosamide dose, pearls

A

100-200 mg IV BID
well tolerated
avoid in bradyarrthymia

47
Q

what is ischemic stroke and scales used

A

brain injury due to blood loss to an area of the brain
time of onset critical
NIHSScale mild-4 severe>20

48
Q

how to assess ischemic stroke

A

neuro-imaging
-non contrast CT to rule out hemorrhage (fluid area)
-MRS detect early ischemic changes (dark area)

49
Q

treatment plans for ischemic stroke

A
  • w/in 4.5 hrs of onset (fibrolytics +/- thromboectomy)
  • 4.5-24 hrs sine symptom onset
    large vessel occulsion (thromboectomy)
    small vessel occulsion (heparin inf)
50
Q

fibrolytics agents and AEs

A
  • Alteplase (risk of hemorrhage, stop inf give cryoprecipitate)
  • Tenecteplase
    rare but fatal risk of angiedema (give methylpre, diphenhydramine, ranitide/famotidine, epi)
51
Q

fibrolytics adjunctive therapy options

A

BP control
1st- labetalol, nicardipine
hypertension can cause hemorrhage
hypotension can worsen ischemia

52
Q

contraindications for fibrolytics

A

<18 yo
ischemic stroke w/in 3 months
GI malignacy or GIB w/in 21 days
LMWH w/in 24hrs
unclear time of onset or >4.5 hours
severe head trauma w/in 3 months
DOAC w/in 48hrs

53
Q

BP requirements for thrombolytics

A

bolus <185/110
INF <180/105
goal SBP 160-180

54
Q

endovascular intervention options

A

thromboectomy (only for large vessel occulsions) +/- inter-arterial theombolytics

55
Q

2nd stroke prevention

A

lifestyle/nutrition
smoking cessation
limit ETOH
counsel on substance abuse
HTN
Dyslipidemia
Diabetes

56
Q

post fibrolytic care

A
  • monitor neurologic and bp for 24 hrs
  • high dose stain and aspirin for all pts
  • dual antiplatelet for low NIH stroke x 21 days or those w/ intracerebral stent placement
  • DVT prophylaxis for 24 hrs post alteplase
  • anticoag if cardioembolic stroke or hx of afib (small occulsion 3-5 days, large 7-14 days)

critical care (2 decks)

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