Thrombolytic therapy for patients with PE
A 2012 guideline from the American College of Chest Physicians (ACCP) recommends thrombolytic therapy for patients with PE and a systolic blood pressure less than 90 mm Hg and without contraindications (for example, high bleeding risk).
Indications for surgical consultation in the management of CDI
- Hypotension with or without required use of vasopressors
- Fever ≥38.5°C
- Ileus or significant abdominal distention
- Peritonitis or significant abdominal tenderness
- Mental status changes
- WBC ≥20,000 cells/mL
- Serum lactate levels >2.2 mmol/L
- Admission to intensive care unit for CDI
- End organ failure (mechanical ventilation, renal failure, etc.)
- Failure to improve after three to five days of maximal medical therapy
Subtotal colectomy in Clostridium difficile colitis
- toxic megacolon,
- perforation or
- progressive dz not likely to respond to medical therapy alone
Hemodialysis indications in patient with tumor lysis syndrome
- patients who are oliguric or anuric,
- have persistent hyperkalemia, or
- have hyperphosphatemia-induced symptomatic hypocalcemia.
Indications for surgery in infective endocarditis
- Refractory heart failure due to severe valvular dysfunction
- Uncontrolled infection (e.g., periannular abscess, persistent sepsis)
- Infection by resistant organisms (e.g., S. aureus, fungal species)
- Recurrent systemic emboli or large vegetations with severe AI/MR
- Prosthetic valve complications (e.g., dysfunction, dehiscence)
- Aortic abscess indicated by lengthening PR interval
Indication of antifungal treatment in high-risk febrile neutropenia
Continued fever, no source identified, day 4-7
Empiric therapy:
A- Not on anti-Candida prophylaxis:
Add Echinocandin e.g. Caspofungin
B- On anti-Candida prophylaxis:
Add Voriconazole
Febrile neutropenia empiric vancomycin
- Hypotension or other evidence of severe sepsis
- Positive blood culture for gram-positive bacteria (before organism/susceptibility is discerned)
- Pneumonia documented radiographically
- Persistent fever while on empiric antibiotics
- Obvious skin infection or erythema at the site of an indwelling catheter
- History of MRSA infection or known colonization
- Severe mucositis if quinolone prophylaxis has been given or ceftazidime is employed as empiric therapy
Indications for empiric coverage of MRSA in pneumonia patients admitted to ICU
- Respiratory failure requiring mechanical ventilation
- Gram-positive cocci in clusters on good-quality sputum Gram stain
- Known colonization or prior infection with MRSA (positive rapid nasal PCR or any prior isolation)
- Receipt of IV antibiotics during a hospitalization in the prior 3 months
- Recent influenza-like illness
- Necrotizing or cavitary pneumonia
- Presence of empyema
- Risk factors for MRSA colonization
- End-stage renal disease
- Patients who are men who have sex with men
- Living in crowded conditions
- Incarceration
- Injection drug use
- Contact sports participation
Intracerebral hemorrhage surgical intervention
- Cerebellar ICH that is ≥3 cm or causing brainstem compression
- ICH causing obstructive hydrocephalus leading to clinical/neurologic deterioration
- IVH causing hydrocephalus and necessitating EVD
- Posterior fossa hemorrhage >3 cm
- Complicated cases requiring ICP monitoring
VV-ECMO absolute contraindications
- Extended mechanical ventilation (usually more than 7 days)
- Central Nervous System (CNS) catastrophes, including significant anoxic brain injury, diffuse axonal injury, massive intracranial hemorrhage, or herniation
- Irreversible lung disease not amenable to lung transplantation
- Unrecoverable heart condition and not a candidate for heart transplant or Ventricular Assist Device (VAD)
- Chronic severe organ dysfunction such as emphysema, cirrhosis, or renal failure
- Non-compliance due to psychosocial, financial, or cognitive issues, particularly in cases requiring a bridge to device or transplant
VV-ECMO
- Reversible hypoxic respiratory failure (including ARDS)
- Considered when mortality risk is >50% (PaO/FiO₂ <150 on FiO₂ >0.9 and/or Murray Score 2 to 3, AOI 60)
- Indicated when mortality risk is >80% (PaO/FiO₂ <100 on FIO >0.9 and/or Murray Score 3 to 4, AOI >80, APSS 8)
- Hypercarbia with high plateau pressure (>30 mm Hg)
- Severe air leak syndromes (bronchopleural fistula/ barotrauma)
- Respiratory support as a bridge to lung transplant (bridge to transplant)
Contraindications to prone ventilation
- Facial/neck trauma or spinal instability,
- Elevated ICP,
- Recent sternotomy,
- Large burns or lacerations over the ventral body area,
- Massive hemoptysis,
- Hemodynamic instability, or
- High risk for needing CPR/defibrillation.
Indication of prone position in ARDS
- PaO2/FiO2 < 150 mmHg
Indications for patient with acute pancreatitis to be admitted to ICU
- Age > 70 yrs
- Obesity with BMI >30kg/m2
- Patient Requiring ongoing Volume Resuscitation
- Presence of indicators of more severe disease
- Pancreatic Necrosis > 30%
- 3 or more Ranson Criteria
- Pleural Effusion
- CRP > 150 mg/dl at 48 hrs
Indications for urgent thoracotomy in trauma
- Blood loss > 1,500 mL or 1/3rd of blood volume
- Blood loss >200 mL/h (3 mL/kg/h) for 2-4 hours
Indications for ICP monitoring
- GCS < 8 and an abnormal CT scan
- GCS <8 and normal CT with > 2 of the following:
- Age > 40 years
- Motor posturing
- SBP < 90 mmHg
Indications of ancillary test
- After the first test to confirm indeterminate apnea test
- If significant doses of CNS depressants have been administered recently
- Severe facial trauma
- Pupillary abnormalities
- Severe chronic CO2 retention
DKA: When to switch to SC
If 2 out of 3? finding
- Able to eat
- resolve AG
- hco3 more than 18
- pH 7.30
Dialysis indications
Pocket
Indications for urgent dialysis (when condition refractory to conventional therapy)
- Acid-base disturbance: refractory acidemia
- Electrolyte disorder: generally hyperkalemia; occasionally hypercalcemia, tumor lysis
- Intoxications
- Indicated for: methanol, ethylene glycol, metformin, Li, valproic acid, salicylates, barbiturates, theophylline, thallium
- Also consider for: carbamazepine, acetaminophen, dig (also give Digibind), dabigatran (also give idarucizumab)
- Overload of volume (CHF)
- Uremia: pericarditis, encephalopathy, bleeding
OSCE
- Fluid overload that is refractory to diuretics
- Hyperkalemia (serum potassium concentration >6.5 mEq/L) or rapidly rising potassium levels, refractory to medical therapy
- Persistent Metabolic Acidosis (pH <7.1)
- Signs of uremia such as pericarditis, neuropathy, or an otherwise unexplained decline in mental status
King’s College Hospital criteria for liver transplantation (paracetamol liver failure)
- Arterial pH < 7.3, 24 hours after ingestion
- or all of the following:
- prothrombin time > 100 seconds
- creatinine > 300 µmol/l
- grade III or IV encephalopathy
Methanol and ethylene glycol toxicity, dialysis indications
Hemodialysis is indicated in severe toxicity, which we define as follows:
- Metabolic acidosis, regardless of drug level
- Elevated serum methanol or ethylene glycol levels (more than 50 mg/dL; or methanol 15.6 mmol/L, ethylene glycol 8.1 mmol/L), unless arterial pH is above 7.3
- Evidence of end-organ damage (eg, visual changes, renal failure)
OSCE answer
- visual impairment,
- renal failure
- pulmonary edema,
- significant or refractory acidosis
- methanol or ethylene glycol level of >25 mg/dL
Magnesium contraindications
- Myasthenia gravis
- Heart block and cardiac conduction abnormality
- Severe hypocalcemia
- Severe renal impairment
Corticosteroids in ICU
Airway
- croup or post-op ENT/maxillofacial surgery.
Breathing
- anaphylaxis;
- pneumonia:
- chronic obstructive pulmonary disease (COPD);
- Pneumocystis jirovecii.
Circulation
- vasopressor refractory shock, for example, in septic shock.
Endocrine:
- Addison’s disease;
- hypercalcaemia;
- Addisonian crisis in patients who have been on long-term steroid use.
Nervous system:
- myasthenic crisis;
- myxoedema coma;
- brain tumor swelling:
- bacterial meningitis.
Organ donation-post brainstem death testing.
Malignancy
Surgical exploration post CABG
- If drain >500cc in 1 hour
- > 400cc in an hour for 2 hours
- > 300cc in an hour for 3 hours
- > 200cc in an hour for 4 hours
