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What is the most important sign in a critically ill pt? Why? - ✔✔Tachypnea Indicates metabolic acidosis w/ respiratory alkalosis compensation A pt misses dialysis for a few days and comes in with fluid overload. He's tachycardic and tachypneic. On physical exam, you find JVD, pulsus paradoxus (20 mmHg drop during inspiration), and HoTN (80/40) with distant, muffled heart sounds. Lungs are clear to auscultation. What is the dx? - ✔✔Cardiac tamponade; obstructive shock If a pt has a thyromental distance of 2 cm, what can you expect about their airway? - ✔✔Difficult airway w/ an anteriorly displaced larynx A COPD pt comes in with difficulty breathing. He then becomes apneic and unresponsive. How would you ventilate this pt? - ✔✔BVM A pt arrives after falling from a ladder and has a frontal laceration. On examination, you find papilledema and labored breathing w/o being able to clear secretions. What is your biggest concern when intubating this pt? - ✔✔Cerebral edema/increasing ICP Intubation tends to cause an increase in ICP. Administer lidocaine prior to intubation to inhibit vagal stimulation. An ESRD pt w/ hyperkalemia develops dyspnea and requires intubation. Which paralytic agent/NMB should you avoid and why? - ✔✔Succinylcholine Worsens hyperkalemia A pt is admitted after an OD. He starts to have apneic episodes and his SpO2 is dropping. You place him on a non-rebreather mask w/ 100% O2, yet his SpO2 remains at 80%. Why is it not being corrected?
Then, if you try a BVM and it also fails, and video laryngoscopy is unavailable, what is your next best choice for an airway? - ✔✔The pt is having apneic episodes, which means that administering high-flow O2 will be ineffective. Choose an LMA if the BVM fails. What intervention improves outcomes with ROSC after cardiac arrest? - ✔✔Targeted temperature management. 32 - 36 C A shunt means there is perfusion without ventilation. What disease process is an example of a shunt? - ✔✔Pneumonia Which type of respiratory failure occurs with CNS depression after an OD? - ✔✔Acute hypercapnic respiratory failure --> mixed A 50 y/o pt is having a COPD exacerbation. You have tried steroids, bronchodilators, etc. with no improvement. PCO2 is in the 90s, pH is 7.20. You decide to intubate. Vent settings are: VT 375, RR 20, FiO2 .35, PEEP 5. CXR is normal. A few minutes later, his BP drops to 70/40. Lungs are clear/equal. Vent shows peak airway pressure of 55 (high) and plateau pressure of 15. End expiratory hold gives auto-peep of 15. What is the cause of this pt's HoTN and why? - ✔✔Auto-peep is the cause. COPD pts have difficulty exhaling --> pressure buildup in alveoli. We use PEEP for the pressure and to improve oxygenation. Auto-peep comes from breath-stacking --> intrinsic peep. Alveoli enlarge --> high peak airway pressure. All leads to low venous return --> low CO --> HoTN
A 70 y/o pt with CHF presents with SOB, accessory muscle use, RR 34, SpO2 90% on 8L O2. CXR reveals infiltrates in a bat wing pattern. She also has LE edema. She is dx with a CHF exacerbation w/ respiratory failure. Her ABG shows pH 7.3, PO2 64, CO2 50. What is the best tx for this pt? - ✔✔Non-invasive BiPAP. A pt comes in w/ a femur fx and a rod is placed. Post-op he develops dyspnea and fever. HR 140, RR 30, SpO2 92% on non-rebreather. He is transferred to the ICU where you intubate, place a central line, and start resuscitating him. Hb 8.2, lactate 3.2, SVO2 is 52%. Why is his SVO2 low? How can we improve it? - ✔✔Decreased O2 delivery and increased consumption. (normal is 65-70) Administer packed RBCs - 1U of blood will change his Hb from 8.2 to 9.2. O2, fluid, and VT would not work. A young pt after an MVA comes to the ER hypotensive and tachycardic. CXR is clear. He has a contusion on his chest wall and torso. He is unconscious. What will give you the best insight on what is causing his shock? Hb SCV Urine Output FAST exam - ✔✔FAST exam 41 y/o pt in the SICU following debridement of b/l lower extremities for necrotizing fasciitis is intubated on AC. Temp 102, HR 116, RR 16, BP 92/46. ABG shows pH 7.23, PO2 133, PCO2 38, Na 139, K 3.7, Cl 102, Bicarb 16, lactate 4. Dx is metabolic acidosis w/ anion gap d/t infection. What is the most appropriate intervention?
Increase VT Continue resuscitation Decrease RR Administer bicarb - ✔✔Continue resuscitation. Don't need to increase VT bc the pt doesn't have respiratory acidosis. If you decrease the RR, the pt will go into respiratory acidosis. A pt has obstructive uropathy. A catheter is placed d/t the obstructive kidney injury. After the cath is placed, he has massive diuresis to the point where he is hypotensive, tachy, and lactate is 2x the ULN from decreased perfusion. How would you correct this? - ✔✔Fluids - LR When treating hyponatremia, what is the first thing to assess? When do you give 3% NaCl? How do you correct it? - ✔✔1. fluid status
- seizures or changes in mental status
- slowly, 8-12 meq over 24 hr What are the classifications of hemorrhagic shock? - ✔✔I: <15%; HR <100, BP normal, RR normal II: 15-30%; HR >100, BP normal, RR 20- 30 III: 30-40%; HR >120, BP low, RR 30- 40 IV: >40%; HR >140, BP low, RR > An 84 y/o pt fell down the stairs. He is moaning and crying. He has a C-collar in place. His neck is painful and he has bruising on his face. He is tachy but BP is okay. You administer 2L O2 bc SpO2 was 92%. Shortly after he deteriorates, becoming altered and then comatose. His left pupil > the right. He is herniating from cerebral edema.
if MSSA: zosyn + ceftriaxone What is the tx for meningitis? - ✔✔young pt: ceftriaxone + vanco
50 pt: add ampicillin A chemotherapy pt becomes septic. You suspect a neutropenic fever. What is the tx? - ✔✔broad spectrum abx (vanco/zosyn) obtain blood, urine, and sputum culture CXR + CT What is the tx of hyperkalemia? - ✔✔calcium gluconate + insulin + dextrose bicarb, kayexalate, albuterol definitive tx: dialysis How do you manage DKA? - ✔✔Check potassium Multiple L bolus via at least 2 peripheral IVs Insulin infusion, 0.1U/kg/hr until sugar reaches 250 mg/dl
Switch NS to D5W Once anion gap is closed, administer long-acting insulin 1 hr prior to d/c infusion A 70 y/o pt with COPD comes in with an exacerbation. He is rapidly becoming more hypoxic. To rule out PE, what test should you order? - ✔✔CT
A 22 y/o pt ingested drugs >4 hours ago. She came to the ICU obtunded w/ arousal to tactile stimulation. She is hemodynamically stable. RR 8 with an NG tube in place. What is the next step for tx of the ingestion? - ✔✔Monitor / watchful waiting. The pt ingested the drugs more than 4 hours ago. Monitor RR and intubate if necessary. A pt presents with HTN, ripping/tearing pain to the back, and unequal pulses. What is the dx? What is the tx goal and what should you use? What medication is contraindicated? - ✔✔1. aortic dissection
- lower BP and HR
- Labetalol, no reflex tachycardia
- Nitro is contraindicated What decreases during pregnancy by ~25%? - ✔✔Functional residual capacity A 24 y/o male comes in following a concussion. CT reveals a frontal lobe contusion. He does not require intubation and is kept on 3 L O2 NC. He then suddenly has a generalized seizure. What is the DOC? What do you give after the seizure? What med class is an absolute contraindication for seizures? - ✔✔1. lorazepam IV
