week 2 status epi, acute stroke, ACLS, Sepsis, pain/agitation/sedation/delirium Flashcards
step plan for analgesia
- give boluses or infusion of opioids
- prn opioids (PCA)
step pain for sedation
- when agitation not controlled by opioids
- propofol, presadex, ketamine
- prn boluses of benzos
step by plan for delirium
- screen + identify early
- non-pharm interventions
scales for analgesia
CPOT goal <2
BPS goal <5
opioid options for analgesia and clinical pearls , ae
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
non-opioid options for analgesia; clinical pearls
- 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
Modifiable risk factors for delirium
- benzo use
- blood transfusions - only when hgb <7
Non-Modifiable risk factors for delirium
- age, dementia, prior coma, pre-icu emergency surgery/trauma
scale for delirium
ICDSC score<4
Non-pharm interventions for delirium
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
Agents for delirium
*only treatment not prevention
- 1st line: presadex
-opioids
- melantoin
- antipsych
sedation scales
RASS -2 light sedation
SAS 3-4
sedation agents- propofol
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
sedation agents- Precedex
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
sedation agents- benzos
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
sedation agents- ketamine
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
neuromuscular blockers monitoring
2 twitches is goal, >2 means not enough sedation, <2 means too much
NMB indications
facilitate mech vent
dec o2 consumption (resp distress)
inc muscle activity
inc intracranial or abdominal pressure
surgical procedures
rapid sequence tubation
NMB drugs and pros/cons
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
identifying sepsis 2 criterias
-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
sepsis 1st hr Bundle
- 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
abx timing for sepsis
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
when to give MRSA coverage
hx of MRSA
recent IV abx
hx of reoccurring skin inf/wounds
presence of invasive devices
recent hosp admin
severity of illness
when to give multi-drug resistant coverage and regimen
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
what is refractory shock and how to treat
poor response to fluids + vasopressors
- high dose corticosteroids or NE +/- vasopressin
which cardiac rhythms are shockable vs non-shockable
shock: VF, pVT
non-shockable: PEA, Asystole
what drugs can be admin endotrachaeal route and conversion
2-2.5: 1 IV/IO
NAVEL drugs; naloxone, atropine, vasopressin, epinephrine, lidocane
dilute w/ 5-10 ml sterile H2O or NS
role of epi in ACLS and when to use, dose
- 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
Antiarrhytmics AC;S
- admin after 3 shocks in VF, pVT
- lidocaine (do not use with norm QT interval)
- amiodarone (bradycardia, hypotension, qt prolongation)
6Hs (reversible causes) of ACLS and treatment)
Hypovolemia (fluids)
Hypoxia (100% o2 mask)
Hydrogen ion acidosis (bicarb)
Hyperkalemia (Bicarb, insulin, dextrose, diuresis, dialysis)
Hypothermia
Hypoglycemia
5Ts (reversible causes) of ACLS and treatment)
Tension pheumothorax (needle decompress)
Tamponade (needle to drain)
Toxins (naloxone-opioids, lipid emulsion-anesthesia, bicarb-antidepress)
Thrombosis ( pulmonary-alteplase, coronary- tenecteplase & PCI)
provoked causes for seizures
intoxification
w/drawal
trauma
meningitis
psychiatric
metabolic derangements
first line agent to stop active seizures
benzos; lorazepam 4mg> diazepam 5-20mg, midazolam max 10mg
- impaired consciousness, resp depression, hypotension
- give during first 10 mins
agents to prevent seizures
antiepileptics- phenytoin, leviteracetam, valporic acid, lacosamide
how to treat super refractory status epi
ketamine inf
load 1.5-3 mg/kg iv once
MainD 0.1-4 mg/kg/hr max 15mg/kg/hr
how to treat refractory status epi
High dose benzos
-Midazolam bolus/inf
- Propofol IV inf (only use if pt intubated)
- Phenobarb or pentobarb (only use if pt intubated)
goal of therapy for status epi and monitoring
burst suppression for 24-48 hrs
slow titration while monitoring LTM Midazolam should be titrated off early because it accumulates in fatty tissue
post intubation treatment (seizures)
paralytic for intubation
iv inf of antiepi (propofol or midazolam)
long term EEG monitoring
2-3 IV antiepi + 1 continous IV inf
what is refractory SE
no response to anticonvulsants; seizures lasting >2 hr OR recurring 2 or more episodes per hour w/o recovery to baseline despite treatment
phenyotin conct calculations
norm= (cp obs)/(.275x albumin) +0.1
poor renal norm= (cp obs)/(.1x albumin) +0.1
Phenytoin AEs
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
phenytoin dose, metabolism and risk
- LD 20mg/kg IV, MD 4-6mg/kg/day
- highly protein bound
- CV: hypotension, bradycardia, QT prolongation **slow titration to mitigate
phenytoin monitoring
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)
Leviteracetam dose, AE
LD 60mg/kg max 4500 mg, MD 1000 mg IV BID
AE- agitation and drowsiness
Valporic Acid dose, monitor, AE
LD 40mg/kg max 3000, MD 5mg/kg IV Q8H
- goal level 50-100
- AE: thrombocytopenia, Hyperammonemia > pancreatitis (peds), HA, drowsiness
Lacosamide dose, pearls
100-200 mg IV BID
well tolerated
avoid in bradyarrthymia
what is ischemic stroke and scales used
brain injury due to blood loss to an area of the brain
time of onset critical
NIHSScale mild-4 severe>20
how to assess ischemic stroke
neuro-imaging
-non contrast CT to rule out hemorrhage (fluid area)
-MRS detect early ischemic changes (dark area)
treatment plans for ischemic stroke
- 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)
fibrolytics agents and AEs
- Alteplase (risk of hemorrhage, stop inf give cryoprecipitate)
- Tenecteplase
rare but fatal risk of angiedema (give methylpre, diphenhydramine, ranitide/famotidine, epi)
fibrolytics adjunctive therapy options
BP control
1st- labetalol, nicardipine
hypertension can cause hemorrhage
hypotension can worsen ischemia
contraindications for fibrolytics
<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
BP requirements for thrombolytics
bolus <185/110
INF <180/105
goal SBP 160-180
endovascular intervention options
thromboectomy (only for large vessel occulsions) +/- inter-arterial theombolytics
2nd stroke prevention
lifestyle/nutrition
smoking cessation
limit ETOH
counsel on substance abuse
HTN
Dyslipidemia
Diabetes
post fibrolytic care
- 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)
