RCE 2021 > ICU > Flashcards

ICU Flashcards

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1
Q

Types of Shock

A
  1. Sepsis - loss vascular tone
  2. Hypovolemic - loss preload
  3. Obstructive - inc after load (PE, tamponade, constrictive pericarditis)
  4. Cardiogenic - pump failure (ACS, valvular)
  5. Anaphylactic/distributive - SIRS, endocrine, mitochondrial dysfunction
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2
Q

Central venous O2 sat

A
  • Get from CVC (SVC), normal 60-65%
  • Mixed central is from pulmonary artery catheter (SVC and IVC), normal 65-70%

ScvO2 >80% = sepsis
- Cells of body are too sick to extract O2 from blood and blood is in high flow state
ScvO2 <60% = cardiogenic
- Heart can’t pump blood with O2 to cells

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3
Q

Sepsis and Septic Shock definitions

A
  1. Sepsis - life threatening organ dysfunction by dysregulated host response to infection. Mortality >10%
    - qSOFA score
  2. Septic shock - subset of sepsis with profound circulatory, cellular, metabolic abnormalities. Mortality >40%
    - Lactate >2
    - Need pressers for MAP >65 in absence of hypovolemia
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4
Q

qSOFA score

A 
2/3 of:
1. RR>22
2. SBP <=100
3. Altered LOC (GCS<15)
If positive = think infection
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5
Q

Surviving Sepsis Categories

A
  1. Initial resuscitation
  2. Abx - empiric broad spectrum
  3. Fluid - crystalloid>colloid, 30 mL/kg bolus
  4. Vasopressors - NE > vaso, epi
  5. Steroids - if refractory septic
  6. Blood - RBC if Hb <70, plt <10 or <50 and bleeding
  7. Mech vent - lung protective ventilation
  8. Adjunctive
    - Bicarb - only pH <7.15
    - Nutrition
    - DVTp
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6
Q

Sepsis 1st hour

A
  1. Lactate - repeat q2-4 if >2
  2. Cultures
  3. Broad spec ABx
  4. IVF - 30 mL/kg for HOTN or lactate >4
  5. Pressors if HOTN for MAP 65+
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7
Q

Which fluid for sepsis?

A

Crystalloid (RL) unless CI

  • HyperK
  • Mitochondrial disease
  • TBI
  • Can use albumin in addition if significant amount of crystalloid given
  • No bicarb if pH >7.15
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8
Q

How much fluids in sepsis?

A
  1. 30 mL/kg in first 4 hours
  2. Then use dynamic measures to determine ongoing needs:
    - NOT CVP
    - Passive leg raise
    - Fluid challenge - inc SV/CO by 10-15% after 250-500 cc
    - Pulse pressure variation
    - Stroke volume variation
    - IVC variation distensibility index - int/vent >15-20% likely, not int >40% likely, low doesn’t mean non responder
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9
Q

Why do you need to know if your patient is fluid responsive?

A
  1. If you have maximized their preload then giving more fluid won’t help their blood pressure/perfusion
  2. If you give more fluid than they need you risk ARDS, AKI, intra abdominal compartment syndrome
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10
Q

Vasopressors

A
  1. NE - alpha effect, 0.03-0.35, can add vast or eps
  2. Vasopressin - 0.03 u/min
  3. Epi - increases lactate (can’t use to guide)
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11
Q

Adrenergic receptors

A

Alpha 1 = inc SVR
Alpha 2 = dec SVR (clonidine)
Beta 1 = inc chronotropy (rate), inotropy (contractility), domotropy (conduction)
Beta 2 = relax smooth muscle/GB/uterus, bronchodilator

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12
Q

Phenylephrine

A

Alpha 1

  • Reflex bradycardia
  • Use in opioid induced HOTN
  • Dec HR and CO, inc SVR and PCWP
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13
Q

Norepinephrine

A

Alpha 1, a bit of beta 1

  • 0.03 - 0.3 mcg/kg/min
  • Inc HR, CO, SVR and PCWP
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14
Q

Dopamine

A

High dose - alpha 1
Low dose - beta 1/2
High risk tachy vs. NE
- Inc HR, CO, SVR, PCWP

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15
Q

Epinephrine

A

High dose - alpha 1
Low dose - beta 1/2
High risk of tachy vs. NE
- Inc HR, CO, SVR, dec PCWP

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16
Q

Dobutamine and isoproterenol

A

Beta 1 and Beta 2

- Inc HR/CO, dec SVR/PCWP

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17
Q

Milrinone

A

Beta 1 and Beta 2

  • NOT in renal failure
  • Very long half life
  • Inc HR/CO, dec SVR/PCWP
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18
Q

Vasopressin

A

Works on its own V1 receptor causing vasoconstriction = inc SVR
Can cause digit and gut ischemia
- Inc SVR/PCWP

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19
Q

Steroids in Sepsis

A

Only if REFRACTORY septic shock- not responding to IVF and pressors
Hydrocortisone 200 mg/day total
- 100 mg loading dose
- 50 mg QID x5-7 d

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20
Q

Hypoxemic Respiratory Failure - Type 1

A
  • PaO2 <60
  • V/Q mismatch
  • Low FiO2, diffusion, alveolar, shunt
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21
Q

Hypercapneic respiratory failure - type 2

A
  • PaCO2 >45

- Can be accompanied by hypoxemia

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22
Q

Post operative respiratory failure

A
  • Atelectasis, low FRC

- Secondary chest wall/anesthetic

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23
Q

Circulatory collapse respiratory failure

A
  • Shock

- Severe acidosis

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24
Q

HFNC

A
  • Humidified O2, up to 60 L/min
  • AGMP - PPE***
  • May help reduce rates of intubation
    Benefits
  • Dec constriction, inc secretion clearance
  • Dec dead space
  • Dec upper airway resistance
  • Recruit atelectasis
  • Inc FiO2
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25
When to use NIPPV
Definitely - Mild-sev acidemia COPD (CO2>45, pH<7.35, RR>20-40) - Cardiogenic pulmonary edema (excl MI, cardiogenic shock) Probably - Post extubation ARF prophylaxis (>65, underlying heart/lung disease) - Post op ARF (supra diaphragm, GI+eso, pelvic *ensure no concern for anastomotic leak) - Palliative ARF - Immunocompromised ARF DO NOT USE - Non acidotic COPD - Failed extubation
26
NIPPV Harms
- Delayed intubation - Unrecognized deterioration - Not lung protective
27
Contraindications to NIPPV
- Facial surgery, trauma - Dec LOC - Can't clear secretions - Respiratory arrest - HD unstable - Indication for intubation - AGMP!!! Watch for COVID
28
Goals of mechanical ventilation
1. O2 delivery 2. A-B homeostasis 3. Airway protection
29
MV improves oxygenation by:
1. Increasing FiO2 delivered 2. Reducing VQ mismatch - PEEP opens alveoli 3. Reduce shunting
30
Volume control
Trigger: ventilator/time Target: Flow Cycle off: volume Variable: pressure
31
Pressure control
Trigger: ventilator/time Target: pressure Cycle off: time Variable: volume
32
ACPC
Trigger: ventilator +/- patient Target: pressure Cycle off: time Variable: volume
33
ACVC
Trigger: ventilator +/- patient Target: flow Cycle off: volume Variable: pressure
34
SIMV
Trigger: ventilator +/- patient Target: varies Time off: time for variable breaths
35
Pressure support
Trigger: patient Target = pressure Cycle off: flow Variable: volume and rate
36
Initial MV Settings
Mode: pressure or volume, assist or control Tidal volume: ARDS 4-8 cc/kg RR: except for PS PEEP, FiO2, trigger, cycle off, alarms/backup Re assess
37
ARDS pathophys
``` Pathophys: - Alveolar damage - Hyaline membrane deposition - endothelial damage/permeability Causes: - Local: PNA, contusion, aspiration - Systemic: sepsis, pancreatitis, drug, TRALI ```
38
ARDS definition
1. Onset within 1 week of insult 2. Bilateral opacities on CXR (pulmonary edema) 3. Not due to cardiogenic/vol overload 4. PF ratio with PEEP >=5 a. Mild 200-300 b. Mod 100-200 c. Sev <100
39
ARDS Treatment
1. Tx underlying cause 2. Provide oxygenation 3. Protect the lungs 4. ICU best practices
40
ARDS - Lung protective ventilation
1. Tidal volume 4-8 cc/kg (based on predicted weight from height) 2. Proning in severe for >12 hrs/day 3. Plateau pressure <30 4. Higher PEEP/FiO2 if mod-sev Targets 1. pH 7.25-7.35 2. PaO2 55-80 3. O2 sat 88-95%
41
Pros and Cons of PEEP
``` Pros 1. Alveolar recruitment 2. Decrease strain on lungs 3. Decrease atelectrauma Cons 1. Alveolar overdistension 2. Intrapulmonary shunt 3. Increased dead space 4. High pulmonary vascular resistance ```
42
ARDS with high FiO2
Should use a higher PEEP strategy! | If FiO2 >50%
43
Mortality benefit in ARDS
``` Reduce mortality - High PEEP - Prone positioning Equivocal - Recruitment maneuvers (not routine) - NM blockade (consider if PF<150, vent dyssynchrony or difficult lung protection) - ECMO - Diuresis/IVF Increased mortality - High Hz oscillation No benefit - Statins, inhaled NO (bridge, improves oxygenation), steroids ```
44
General COVID Recommendations
- AGMP = wear N95, negative pressure room - Most experienced person intubates - Use NE>epi>dop - no hydroxyethyl starches - use crystalloids - Dex 6 mg IV daily x 10 days - No interferon, convalescent plasma, HCQ - Remdesevir controversial
45
COVID Ventilation Recommendations
- Suggest O2 <92%, recommend <90% - Target no >96% - If NIPPV/HFNC monitor closely for deterioration and need for intubation - Plat pressure <30 - Higher PEEP strategy
46
COVID O2 Algorithm
- PF >150 = facemask - PF <150 = intubate - TV 6, PEEP 10, RR 15, FiO2 1
47
Weaning from MV
Consider if: 1. Reversed underlying cause 2. Cardiac stable 3. Adequate mentation 4. Oxygenation - FiO2<40, PEEP 5-8, PaO2>60 5. Other: lyes, A-B, pain control
48
Spontaneous Breathing Trial
- Attempt to mimic them breathing on their own - ETT inc resistance = harder than breathing on own - Should do SBT on pressure support for shorter period of time instead of t piece for longer - Ex. PS 5/0 - Can estimate RSBI
49
RSBI
Rapid shallow breathing index = RR/Tidal Volume RSBI>105 = failed extubation
50
RASS
``` Target RASS -2 to +1 +4 = combative, violent dangerous +3 = pull/remove tubes/cath, aggressive +2 = frequent non purposeful movement +1 = anxious, apprehensive 0 = alert and calm -1 = awaken to voice, eyes >10 s -2 = lid sedation, brief <10 s -3 = mod sedation, move/open eyes -4 = deep sedation, no response to voice, respond to physical stimulus -5 = unrousable, no response ```
51
ICU Sedation Options
- Prefer propofol or Precedex > benzos - Daily awakening trial - Stop infusion ASAP
52
ICU Delirium
Non Pharm - Sleep, mobilize, hearing/vision aids, orient, daylight, family Pharm - Nothing shortens course - Atypicals preferred ex. quetiapine - Consider Precedex if preventing weaning/assess extubation
53
ICU Pain management
- Multimodal - Tylenol and NSAID - Opioids esp post op - Low dose ketamine and lidocaine = adjuncts - Neuropathic = gabapentin, carbamazepine, pregabalin - Regional anesthesia- epidural, nerve blocks
54
ICU Sleep
Non Pharm - Ear plugs, eyeshade, relaxing music, schedule, light/dark - NO PROPOFOL - Unclear Precedex/melatonin
55
Post arrest TTM
- Any rhythm - In or out of hospital arrest - Target Temp 33-36 (or 32-34) --> upper limit if arrhythmia or CV unstable - Minimum 24 hours, longer if need to prevent fever
56
Brain death
Irreversible cessation of cerebral and brainstem function
57
Persistent vegetative state
Severe anoxic brain injury progressing to a state of wakefulness without awareness No purposeful response Sleep wake intact
58
Minimal conscious state
Limited interaction with environment with visual tracking +/- simple commands Intelligible verbalization or something yes/no but not always appropriate
59
Locked In
Retained alertness, cognitive abilities, can move eyes and blink voluntarily but paralysis of limbs and oral structures
60
Neurologic Determination of Death
1. 2 physicians 2. Etiology compatible with NDD 3. No confounding factors: umresuscitated shock, T<34, sev metabolic, NM block, peripheral neuropathy/myopathy, drug interactions **if you can't correct these then use ancillary testing 4. Absent brain stem reflexes - pupillary, corneal, gag, cough, oculovestibular (cold calorics - towards cold) 5. Absent movement - spont + noxious (bilateral AND above/below clavicles). EXCLUDES spinal reflexes 6. Apnea testing
61
Apnea testing
1. Correct confounders 2. Pre oxygenate and get ABG (want CO2 35-45, pH 7.35-7.45) 3. Disconnect vent 4. Monitor resp efforts 5. Serial ABGs Complete when: 1. CO2>60 2. CO2 >20 above baseline 3. pH <=7.28
62
NDD Post cardiac arrest
Must wait AT LEAST 24 hours before NDD
63
NDD Confounding Factors
- May over rule by 2 physicians - Therapeutic anti epileptics don't count - Lab recommendations: pH 7.35-7.45, Na 125-159, phos >0.4, Gluc 3-20
64
Ancillary testing
``` Want to demonstrate absent cerebral flow. Use this if can't fix confounders. 1. Radionuclide angiography 2. CT angiography 3. 4 vessel angiography 4. MR angiography NOT EEG!! ```
65
Donation after Cardiocirculatory death
Controlled death - Withdrawal life support (consent, routine EOL care) - 2 physicians confirm death (not from transplant team) - Min 5 mins observed with NO pulse, BP, Respiratory effort - Can happen in ICU or OR - Maximum time is 1-2 hours
66
Critical illness myopathy
``` Motor - Flaccid quadriparxsis - Proximal>distal - Failure to wean - Normal CN - Weak facial muscles Sensory - Spared Reflex - Normal or low Other - CK may be up - Associated with steroids - Dx with NCS/EMG - No treatment ```
67
Critical illness polyneuropathy
``` Motor - Flaccid quadriparesis - Distal>proximal - Failure to wean - Normal CN Sensory - Dec pin prick/touch in distal Reflexes - Low Other - Sev sepsis risk factor ```
68
Steroid Induced Myopathy
``` Motor - 1-3 mos after starting steroids - Proximal lower>upper limb - Muscle atrophy Sensory and Reflexes - Normal Other - Cushing's like syndrome - DM, mood, skin, OP - Tx - dec steroid dose and improves ```
69
Risk Factors for critical illness neuropathy/myopathy
25% pts vented for at least 7 days COPD/asthma, liver tx, ARDS, steroid use Hyperglycemic, hyperthyroid
70
Osmolar gap calculation
Serum Osm - Calc Osm | Calc Osm = 2Na + gluc + BUN + 1.25ETOH
71
Sympathetic toxidrome
Vitals - BP, HR, Temp HIGH - RR normal Eyes = mydriasis (dilated) Skin = sweat Mental status = agitated Ex. cocaine
72
Anticholinergic toxidrome
``` Vitals - BP, HR, Temp HIGH - RR normal Eyes = mydriasis (dilated) Skin = dry/hot Mental status = agitated/mad Ex. Gravol ```
73
Cholinergic toxidrome
``` Vitals - BP, HR, Temp LOW - RR HIGH (low sats) Eyes = miosis (constricted) Skin = wet/cool Mental status = N/A Ex. organophosphates ```
74
Opioid toxidrome
``` Vitals - BP, HR, RR, temp LOW Eyes = pinpoint (constricted) Skin = N/A Mental status = dec LOC Ex. fentanyl ```
75
TCA Overdose Symptoms
- TCA is an anticholinergic - CVS: HOTN, arrhythmia (sinus tachy, wide QRS --> VT/VF) - CNS: dec LOC, agitation, psychosis, delirium, seizures
76
TCA OD Labs
- Serum levels NOT helpful - Can detect on URINE tox - False positive if quetiapine, Benadryl or cyclobenzaprine - Respiratory acidosis - ECG
77
TCA ECG
- Wide QRS >100 - Tall R in AVR - Deep slurred S in 1 and AVL - Type 1 Brugada - RBBB, downsloping STD in V1-V3
78
TCA OD Treatment
- ABC, MOIF, Poison Control - Decontamination - activated charcoal if >2 hrs (slowed gastric emptying) unless dec LOC, perforation or bowel obstruction - No inc elimination - No antidote - May need to tx ALOC/seizures, QTc/arrhythmia
79
TCA LOC management
- GCS 8 intubate - Seizures: a. Ativan/diazepam b. Midazolam infusion c. Propofol infusion d. Barbiturates NO PHENYTOIN - cardiac tox
80
TCA HOTN
NS or sodium bicarb up to 30 cc/kg | NE if refractory
81
TCA WCT Tx
1. Bicarb 1-2 cc/kg IV --> if QRS narrows start infusion at 250 cc/hr (3 amp in 1L D5) 2. MgSO4 3. Lidocaine 1.5 mg/kg bolus then infusion 1-4 mg/min 4. Lipid emulsion 5. VA ECMO (not VV)
82
TCA Sodium Bicarb Indications
1. QRS>100, target <120 2. Ventricular arrhythmia 3. HOTN pH target 7.5-7.55 Bolus 1-2 amps then infusion 250 cc/hr
83
Ethylene Glycol
- Antifreeze, wiper fluid, cleaners, fuels, moonshine - Dec LOC - Flank pain, oliguria, hematuria - HypoCa - CN palsy Inv - High AG and OG - QTc from hypoCa
84
Methanol
- Antifreeze, piper fluid, cleaners, fuels, moonshine - Dec LOC - Retinal injury = blind - RAPD, mydriasis, retinal sheen, hyperaemia optic disc - High AG and OG
85
High AG, no OG
- DKA/starvation ketosis - Lactic acidosis - Tylenol - Salicylates - Late toxic alcohol
86
High AG, high OG
- Methanol - Ethylene glycol - Propylene glycol - ETOH/DKA - ESRD no IHD
87
No AG, high OG
- Isopropyl alcohol - Ethanol - Sev hyperparaproteinemia/hyperlipidemia - Early toxic alcohol
88
Toxic alcohol tx
- ABC, MOIF - Decontaminate - no role (maybe NG asp if 60 mins) - No treatment - Enhanced elimination (methanol) - bicarb bolus then infusion, target pH 7.35 - ADH - HD - Folic acid 50 mg q4hr
89
Toxic alcohol tx inhibition
- Inhibit ADH - fomepizole or ethanol Indications - Methanol >6.2 or Ethylene glycol >3.2 - Recent hx ingestion of toxic amounts of either with OG>10 - Suspect ingestion and 2 of: pH <7.3, bicarb <20, OG>10, urine oxalate crystals
90
Toxic alcohol HD
- Definitive therapy - Indications: 1. High AG metabolic acidosis 2. End organ damage (eye) or renal failure
91
Ethanol level
Intoxication 4-10 | Account in OG calculation
92
Isopropyl alcohol tx
Supportive
93
ASA toxicity Early
- Tinnitus - N/V - Hyperventilation - Fever
94
ASA toxicity late
- Coma/seizures (from cerebral edema) - Non cardiogenic pulmonary edema - Arrhythmia - Thrombocytopenia - AKI
95
ASA toxicity glucose
Discordance between serum and CSF glucose concentrations Can have NORMAL serum with LOW CSF Give 1 amp D50W Usually once ASA>3
96
ASA tox labs
- Toxic serum level >2.9-3.6 - Check q2-4 hr - Respiratory alkalosis PLUS AGMA - If you see resp acidosis think: acute lung injury, CNS depression, mixed overdose (Benzos, alcohol)
97
ASA Overdose Tx - Decontamination
- Activated charcoal 1 g/kg up to 50 g via PO/NG - Given within 2 hours - can be longer if enteric coated ASA - Consider whole bowel irrigation - +/- intubation
98
ASA Overdose Tx - Enhanced elimination
- Alkalinize urine/blood - Targets: blood pH 7.4-7.5 and urine 7.5-8 - Bicarb bolus and infusion 250 cc/hr (watch K, Na, Ca) - Correct hypoK first!
99
ASA Overdose Tx - Dialysis
``` Indications: LA SHARP - Liver problem with coagulopathy - ASA >7.2 acute (>3 chronic) - Sev A-B/lytes - Hypoxemia - ALOC - Renal failure (with level >6.5) - Progressive deterioration of vitals ```
100
Serotonin Syndrome | Symptoms and Timing
1. Autonomic: inc HR, inc BP, N/V/D, fever, sweaty 2. NM: tremor, rigid lower>upper, myoclonus, hyperreflexia, bilateral babinski, ocular clonus 2. AMS: anxiety, agitated, restless, disoriented Onset within 24 hr, off within 24 hr
101
Neuroleptic malignant syndrome
FARM Fever - >38 Autonomic - tachy, labile BP, sweaty, dysrhythmia Rigidity - lead pipe/cogwheel, NO CLONUS, hyPOreflexia Mental status - agitated, delirium, catatonia, coma On days-weeks, off 2 weeks
102
Serotonin Syndrome | Meds
Meds: SSRI, TCA, SNRI, NDRI, MAOI, amphetamines, cocaine, MDMA, levodopa, tramadol, meperidine, St. John's Wart, VPA, triptans, ergot, fentanyl, buspirone
103
Serotonin Syndrome Dx Criteria
Hunter Criteria Take a serotonergic agent and one of: - Spontaneous clonus - Ocular clonus - Inducible clonus + diaphoresis and agitation - Tremor and hyperreflexia - Hypertonic + T>38 plus ocular or inducible clonus
104
Serotonin Syndrome Tx
- Stop agent - Supportive - Sedate with Benzos - If fail - cyprohepatadine
105
NMS Meds
- All neuroleptic drugs - Quetiapine, clozapine, risperidone, olanzapine - Antiemetic - domperidone, metoclopramide, prochlorperazine
106
NMS Tx
1. Stop agent 2. Supportive 3. Cooling blankets 4. Benzos 5. Dantrolene and bromocriptine
107
Fluid Choices
- Bicarb only for sev AKI/acidosis, pH<7.15 | - Albumin is safe but doesn't affect outcomes much
108
Fluid responsiveness assessment
- CVP very unreliable | - IVC diameter is pretty unreliable
109
Dexmedetomidine
- Central acting adrenergic alpha 2 - Sedating and calming while maintaining rousal - SFx: bradycardia, HOTN
110
ACLS Compression Rate
100-120 bpm
111
ACLS Chest compression depth
5-6 cm Allow recoil Use backboard
112
Defibrillate in shockable rhythm
ASAP
113
Interruptions in CPR
- Intubation shouldn't interrupt | - No more than 10 sec interruption at a time
114
ACLS naloxone
Reasonable adjunct to give if suspected opioid associated emergency
115
ACLS local anesthetic toxicity
Lipid emulsion can be given or if other drug toxicities
116
Amiodarone/Lidocaine in ACLS
Can give if VF/pulseless VT not responding to defibrillation
117
ACLS Magnesium
Not recommended routinely unless torsades
118
ACLS beta blocker
No evidence to use early
119
ACLS Lidocaine
No evidence to use within 1st hour after ROSC
120
ACLS pregnant
Manual left uterine displacement Prioritize airway management No fetal monitoring TTM after (monitor fetus)
121
Pregnant VT with pulse, stable
Cardioversion: electric, anti arrhythmic, overdrive pacing Non long QT monomorphic: sotolol or procainamide Long QT: beta blocker
122
Pregnant VT with pulse, unstable
Cardioversion - synch, safe, may cause fetal arrhythmia | If refractory use amiodarone (non QT long, monomorphic), lidocaine if prolonged
123
Pregnant VT/VF no pulse
Defibrillate if appropriate Move uterus off IVC once 20+weeks Consider PMCD in later half pregnancy and at 4 mins resusc
124
ACLS Advanced airways
- BMV or advanced airway - Supraglottic/LMA - OHCA - SGA/ETT OHCA high success rate ETT - SGA/ETT in hospital
125
ACLS Vasopressors
Epi 1 mg q3-5 min if cardiac arrest ASAP if non shockable After initial defibrillates attempts if shockable Can consider vaso but no advantage
126
ACLS Extracorporeal CPR
Not enough evidence for routine | Select patients if rescue
127
ACLS Monitor CPR
May use arterial BP or ETCO2 if feasible to monitor quality
128
ACLS Double sequential defibrillation
Not supported for refractory shockable rhythm
129
ACLS IV access
Try for IV before iO
130
Neuroprognostication - poor neuro outcome findings
1. No N2O somatosensory evoked potential cortical wave 24-72 hrs after arrest/rewarming 2. Motor M1/M2 at 72 hours 3. Persistent absence of EEG to external stimuli at 72 hrs 4. Presence of status myoclonus during first 72 hrs 5. Absent pupillary light reflex 72 hours+
131
Desaturation in Vented Patient
1. Check connections 2. Disconnect ETT from vent -and bag ventilate to check for resistance a. Airway - blocked tube, bronchoconstriction, auto PEEP b. Airspace - blood, pus, water, cells, protein c. Pleura - PTX, hemothorax, effusion d. Vascular - PE 3. Deep suction 4. Ausculate - check trachea midline 5. Check other vitals 6. CXR 7. Hx - new line? new blood?
132
Tracheal assessment - ETT migrated
Often to R mainstem bronchus - Trachea to LEFT - Air entry decrease on LEFT - Percussion dec on LEFT
133
Tracheal assessment - PTX
- Trachea away from affected lung - Air entry decreased on affected side - Percussion inc on affected side - May have SC emphysema
134
Tracheal assessment - Collapse
- Trachea towards affected side - Air entry decreased affected side - Percussion decreased affected side
135
Ventilator Issues - hypoxia and hypercapnea management
1. Hypoxia - inc FiO2, inc PEEP, inc sedation and paralyze, proning, ECMO 2. Hypercapnia - inc RR, inc tidal volume, inc I:E ratio
136
Assessing intubation difficulty
1. Grade 3 upper lip bite test 2. Combo findings 3. Short hyomental distance (<3-5.5 cm) 4. Retrognathia (mandible <9 cm from angle jaw to tip chin) 5. Mallampati score 3+
137
Hypothermia rewarming stage I
``` 32-35 Conscious, shivering Tx - Warm environment, clothing - Active movement - Warm drinks ```
138
Hypothermia rewarming stage II
28-32 Impaired LOC, not shivering Tx - Cardiac monitor - Minimal movements, horizontal, immobile - Full body insulation - Active EXTERNAL (heating pack, blankets) - Minimally invasive rewarming (warmed IVF)
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Hypothermia rewarming stage III
24-28 Unconscious, not shivering, vital signs present - Stage II plus airway PRN - ECMO if unstable
140
Hypothermia rewarming stage IV
<24 - no vitals | II and III plus CPR, up to 3 doses of epi (IV or IO) and defib
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Acute liver failure management in the ICU
1. No hydroxyethyl starch for initial fluid 2. NE first line vasopressor 3. Viscoelastic testing >INR/plts/fibrinogen 4. No eltrombopag if TCP before surgery/procedure 5. Vasopressors if HRS 6. Target glucoses 110-180
142
ECG Long QT
"ANTIS" - Antipsychotics - Antiemetics - Antibiotics - Antidepressants (TCA) - Antiarrhythmics - Electrolytes (hypo) - Cocaine
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ECG TCA Toxicity
1. Tall R in AVR 2. Deep slurred S in I/AVL 3. Type 1 Brugada - RBBB with downsloping STD V1-3 4. QRS >100 5. Tachycardia
144
Digoxin toxicity ECG findings and sx
ECG 1. Tachy (VT/VF) or Brady (2/3 degree HB) arrhythmias 2. Accelerated junctional tachycardia DON'T give Ca for hyperK Sx - N/V - Vision blurry - Anorexia Antidote - Digibind - Use if arrhythmia not respond to therapy, K>5, end organ dysfunction
145
Dilated pupils
- Anticholinergic - Sympathetic - cocaine, amphetamines, hallucinogens - TCA - Methanol - Opioid withdrawal
146
Constricted Pupils
- Cholinergic | - Opioids (pinpoint)
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Normal pupils
- Hypothermia - Barbiturates - Antipsychotics
148
Tylenol Toxicity
Antedote = NAC | - Liver tx if failure = INR up, pH down, hypoglycaemia, encephalitis
149
ASA Toxicity
Acute: tinnitus, N/V, hyperventilation, fever Long: coma/seizures, ALOC, non cardiogenic pulmonary edema, TCP, AKI Tx: Bicarb to alkalinize urine and blood, HD (>7.2 acute, >3 chronic)
150
Toxic alcohols summary
Methanol (visual), ethylene glycol (kidneys, oxalate urine crystals) Tx: ethanol, fomepizole
151
Carbon monoxide poisoning
- Fires - Normal finger O2 and PaO2 but SAT on ABG low - Baseline 3% carboxyHb level in non smokers, 10-15% smokers Tx 1. 100% FiO2 2. Hyperbaric if: CO-Hb >25%, or 20% if pregnant, fetal distress, pH <7.1, MI, LOC 3. Intubate if comatose 4. Tx for cyanide poisoning as well if smoke inhalation
152
Cyanide poisoning
- Smoke inhalation, nitroprusside admin - ABG = metabolic acidosis (lactate >8), arterial and venous O2 sats equal - High CN level >2.4 resp dep and coma, >3 = death Tx 1. 100% FiO2 and ETT 2. Cyanokit - hydroxycobalamin 3. Amyl nitrite, sodium nitrite, sodium thiosulfate 4. Methylene blue high doses (old, less effective) NO DIALYSIS
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Organophosphate antidote
Atropine
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Opioid antidote
Naloxone | - Short t1/2 = use drip
155
Benzo antidote
Flumazenil | LOWERS seizure threshold
156
BB/CCB antidote
Glucagon | High dose insulin (infusion with dextrose)
157
GHB tx
supportive care
158
INH antidote
Vit B6
159
Lithium overdose
``` Therapeutic 0.6-1.2 Sx - N/V/D - Inc WBC - CNS sx late - ECG - ST waves flat in precordial, QTc prolong, brady Tx 1. Decontamination - can try WBI (SR, sx, unknown amount, <6 hr, >40 mg/kg) 2. IHD if: - Arrhythmia - Seizures/AMS - Serum 5+ - Serum 4+ if Cr >176 3. IVF ```
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Organophosphate poisoning symptoms
- Insecticides - Reversing NM - Tx MG - Alzheimers Muscarinic - DUMBELS - Diaphoresis, diarrhea - Urination - Miotic pupils - Bronchospasm, bronchorrhea, bradycardia - Emesis - Lacrimation - Salivation Nicotinic - MATCH - Muscle weakness - Adrenergic stimulation - mydriasis - Tachycardia - CNS - HTN
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Organophosphate delayed neuropathy
1-3 weeks after ingestion Stocking and glove parenthesis Painful Then get symmetrical motor polyneuropathy - flaccid weakness of lower extremities
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Organophosphate poisoning tx
1. 100% FiO2, intubate 2. IVF if HOTN 3. Well vented area 4. Atropine if miosis, sweating, HOTN, resp distress, bradycardia
RCE 2021
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