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Critical care Board Review 2008 Antoinette Spevetz, MD, FCCP, FCCM Critical care Board Review 2008 Antoinette Spevetz, MD, FCCP, FCCM

CPR • Outcome is improved in patients with witnessed arrest, those who present in CPR • Outcome is improved in patients with witnessed arrest, those who present in VF or VT • Asystole or PEA has poor survival • On first analysis 40% of victims are in VF • Push hard, push fast, allow full chest recoil and minimize interruptions

CPR • Four links – Early recognition and activation of 911 – Early bystander CPR • Four links – Early recognition and activation of 911 – Early bystander CPR – Early delivery of shock – Early ACLS v

ACLS • Vasopressin may substitute for one dose of epinephrine ACLS • Vasopressin may substitute for one dose of epinephrine

According to ACLS guidelines, which of the following recommendations for vasopressin administration (single 40 According to ACLS guidelines, which of the following recommendations for vasopressin administration (single 40 -U intravenous bolus) us correct? (A) It is not recommended (B) It is an alternative to epinephrine for ventricular fibrillation or pulseless ventricular tachycardia (C) It is an alternative to epinephrine for pulseless electrical activity (D) It is a second-line intervention, following 3 doses of epinephrine for cardiac arrest

 • Which of the following statements is correct regarding in hospital cardiac arrest • Which of the following statements is correct regarding in hospital cardiac arrest and CPR – A. pts who have VF have better outcomes that patients who have asystole – B. asystole is more common than VF in pts with cardiac arrest – C. early use of Ca channel blockers improves neurologic recovery – D. sodium bicarb should be given every 5 min during CPR – E. well performed external cardiac compression usually provides 40 -50% of normal circulatory flow

PEA • Hypovolemia • Hydrogen ion • Hypo/hyperkalemia • Hypoglycemia • Hypothermia • Toxins PEA • Hypovolemia • Hydrogen ion • Hypo/hyperkalemia • Hypoglycemia • Hypothermia • Toxins • Tamponade • Tension pneumothorax • Thrombosis • Trauma

A 55 year old man arrives in the ED in complete cardiopulmonary arrest. Cardiopulmonary A 55 year old man arrives in the ED in complete cardiopulmonary arrest. Cardiopulmonary resuscitation, started by the paramedic team who transported him, is still in progress. Electrocardiographic monitoring reveals a heart rate of 72 per minute but no pulse can be palpated.

Which of the following is the most appropriate next step? (A) Dobutamine infusion (B) Which of the following is the most appropriate next step? (A) Dobutamine infusion (B) Amiodarone infusion (C) Normal saline by rapid infusion (D) Electrical cardioversion (E) Insertion of a transvenous pacemaker

Hypothermia • Unconscious patients with spontaneous circulation after out of hospital arrest should be Hypothermia • Unconscious patients with spontaneous circulation after out of hospital arrest should be cooled to 32 -34 C for 12 -24 hours • Cooling may be beneficial for other rhythms

In which of the following circumstances is induced hypothermia (to 33. 0 C [91. In which of the following circumstances is induced hypothermia (to 33. 0 C [91. 4 F]) most likely to result in improved outcome? (A) Traumatic head injury (B) Comatose survivors of cardiac arrest (C) Stroke (D) Bacterial meningitis (E) Encephalitis

 • In a patient with out of hospital VF which of the following • In a patient with out of hospital VF which of the following is most likely to improve the likelihood of survival with intact neurologic function? – – – A. amiodarone B. dilantin C vasopressin D. induced hypothermia to 33 C F. automated external defibrillation

Pain, Anxiety and Delirium • Must be regularly assessed • Evoke a stress response Pain, Anxiety and Delirium • Must be regularly assessed • Evoke a stress response • Complicate management of life saving devices • Assess pain first using a numeric scale • Assess anxiety and sedation using validated scales (RASS )

Pain, Anxiety and Delirium • Assess delirium with CAM-ICU • Use non pharmacologic means Pain, Anxiety and Delirium • Assess delirium with CAM-ICU • Use non pharmacologic means when possible • Use intermittent bolus when possible and daily sedation vacations • When other factors are ruled out use haldol as the drug of choice • Can see persistent neuropsychological dysfunction in ICU survivors

Inhalation Injuries • Injury can occur as a result of three mechanisms – Direct Inhalation Injuries • Injury can occur as a result of three mechanisms – Direct thermal injury – Low oxygen concentration – Toxic products of combustion

Inhalation Injuries • Initial assessment – Evaluate upper airway – are there burns, soot, Inhalation Injuries • Initial assessment – Evaluate upper airway – are there burns, soot, singed eyebrows, carbonaceous sputum – Intubate if airway compromise or with significant second or third degree burns – Hot gases (steam) can rapidly cause upper airway injury – Upper airway takes the brunt of the damage – usually do not see lower airway damage

Inhalation Injuries • • Tissue edema will worsen over 24 -48 hours Keep intubated Inhalation Injuries • • Tissue edema will worsen over 24 -48 hours Keep intubated at least 72 hours Err on the side of intubation hypoxia or diffuse infiltrates at admission are a poor prognostic sign Normal CXR does not exclude inhalational injury Aggressive respiratory therapy (heliox, racemic epi, elevate HOB) Bronchoscopy No steroids

Inhalation Injuries • Toxic gases – Act as asphyxiants – Cause airway irritation – Inhalation Injuries • Toxic gases – Act as asphyxiants – Cause airway irritation – Function as systemic toxins • CO and cyanide are two most common inhaled systemic toxins • CO is cause of death in 75% of fire fatalities

Inhalational Injuries • CO competes directly with O 2 for Hgb binding, fixes to Inhalational Injuries • CO competes directly with O 2 for Hgb binding, fixes to cytochrome oxidase and displaces the oxyhgb dissociation curve to the left • Breathing 100% O 2 decreases t 1/2 to 3090 minutes • No real benefit to hyperbaric

Inhalational Injury • Closed space fires generate cyanide through combustion of wood, silk, nylon, Inhalational Injury • Closed space fires generate cyanide through combustion of wood, silk, nylon, and polyurethane • May see nml Pa. O 2, O 2 sat, and O 2 content • Mixed venous will be high due to undelivered O 2 • Treatment : amyl nitrate, sodium nitrite, sodium thiosulfate (Lilly kit)

Agents of warfare • Decontamination • Agents – Nerve gas – vaporized liquid (miosis, Agents of warfare • Decontamination • Agents – Nerve gas – vaporized liquid (miosis, salivation, resp failure from diaphragm paralysis) Rx with 2 -PAM and atropine – Chlorine- bronchospasm, pulm edema – Mustard gas – rhinorrhea, airway injury, vesicant causing burns – Phosgene- tracheobronchitis, airway injury, pulm edema, vesicant

Which of the following best describes the earliest radiological findings of inhalation anthrax? (A) Which of the following best describes the earliest radiological findings of inhalation anthrax? (A) Mediastinal widening and pleural effusions (B) Lobar consolidation (C) Interstitial infiltrates (D) Multiple pulmonary nodules (E) Multiple thin-walled cavities

Anaphylaxis Release of mediators from mast cells and basophils triggered by Ig. E allergen Anaphylaxis Release of mediators from mast cells and basophils triggered by Ig. E allergen interaction or by a nonantibody antigen mechanism (foods like peanuts & shellfish, insect stings, latex) Signs &symptoms include urticaria, conjunctival puritis, bronchospasm, nausea, vomiting.

Anaphylaxis • Shock is caused by severe hypovolemia and • • • vasodilitation Death Anaphylaxis • Shock is caused by severe hypovolemia and • • • vasodilitation Death from refractory bronchospasm, upper airway obstruction and cardiovascular collapse Treatment – fluids, epi, intubation, antihistamines, H 2 antagonist, steroids, glucagon if pt is on B blocker (ABCD approach) Monitor for biphasic anaphylaxis • l

Hypertensive Crisis • Hypertensive emergencies – HTN and end organ damage (encephalopathy, cardiac, renal) Hypertensive Crisis • Hypertensive emergencies – HTN and end organ damage (encephalopathy, cardiac, renal) • Hypertensive urgency – no end organ damage

Hypertensive Crisis • Search for secondary cause – Cerebral infarct, ICH – MI, LV Hypertensive Crisis • Search for secondary cause – Cerebral infarct, ICH – MI, LV failure, angina – Dissecting aneurysm – Severe preeclampsia – Renovascular HTN – Abrupt withdrawal from antihypertensives – Drug use

Hypertensive Crisis • Hypertensive urgencies can be discharged from • • the ED. Those Hypertensive Crisis • Hypertensive urgencies can be discharged from • • the ED. Those who are elderly, have h/o stroke, ischemia should be watched HTN emergencies should be admitted to ICU and treated with parenteral agents Goal of therapy is to reduce end organ damage not normalize the BP Decrease the MAP 20 -25 % or diastolic <120 With ischemic stroke cerebral autoregulation is disturbed and BP therapy may worsen situation

Hypertensive Crisis • Oral drugs – Captopril – reflex tachycardia, contraindicate in pregnancy, RAS, Hypertensive Crisis • Oral drugs – Captopril – reflex tachycardia, contraindicate in pregnancy, RAS, potentiated with lasix – Clonidine – sedation, abrupt cessation causes rebound – Labetalol – bronchospasm, careful with diuretic – Prazosin – pheo, can cause syncope, palp, tachy, hypotension

Hypertensive Crisis • Parenteral drugs – Diazoxide – potent arterial vasodilator, lg doses can Hypertensive Crisis • Parenteral drugs – Diazoxide – potent arterial vasodilator, lg doses can cause hypotension and reflex tachy, increases LV contractility, causes increased myocardial O 2 consumption – Enalapril – useful in CHF, contraindicated in pregnancy – Esmolol – usual B blocker stuff – Fenoldopam – selective peripheral dopamine receptor agonist, causes vasodilation of renal bed, decreases preload and afterload (good for LV failure)

Hypertensive Crisis • Hydralazine – arteriolar vasodilator, used in • • • preeclampsia, caution Hypertensive Crisis • Hydralazine – arteriolar vasodilator, used in • • • preeclampsia, caution with hypovolemia, CAD, aortic dissection, causes reflex tachy Labetalol – iv or infusion NTG – venodilator and coronary vasodilator, tolerance develops Nicardipine – decreases cerebral and cardiac ischemia, easy to use Phentolamine – pheo, can cause arrhythmias and tachy Nipride – arterial and venodilator, rapid onset, easy titration, concern over toxicity (thiocyanate) Trimethaphan – ganglionic blocker, aortic dissection

A 70 -year-old man is evaluated in the emergency department because of headache and A 70 -year-old man is evaluated in the emergency department because of headache and mild nausea. Blood pressure is 210/125 mm Hg. He has a long history of hypertension but is not adherent to his antihypertensive regimen. He has not taken any medications for three weeks. He does not use illicit drugs. The patient is admitted to the intensive care unit.

S 1 and S 2 are regular, with a summation gallop. No pulmonary wheezes S 1 and S 2 are regular, with a summation gallop. No pulmonary wheezes or crackles are heard. Funduscopic examination is negative for papilledema. Neurologic findings are nonfocal. Electrocardiogram shows sinus tachycardia with evidence of left ventricular hypertrophy and a strain pattern; no new changes are noted compared with a tracing obtained six months ago.

Laboratory studies Hematocrit 33% Leukocyte count 10, 500/μL Peripheral blood film Microangiopathic hemolysis Blood Laboratory studies Hematocrit 33% Leukocyte count 10, 500/μL Peripheral blood film Microangiopathic hemolysis Blood urea nitrogen 60 mg/d. L Serum creatinine 5. 2 mg/d. L Serum electrolytes: Sodium 135 m. Eq/L Potassium 5. 4 m. Eq/L

Chest radiograph shows slight cardiac enlargement, clear lung fields, and no evidence of pleural Chest radiograph shows slight cardiac enlargement, clear lung fields, and no evidence of pleural effusion. Computed tomogram of the head (without contrast) is normal. Which of the following is most likely to decrease blood pressure and increase blood flow to the kidneys? (A) Clonidine (B) Fenoldopam (C) Nifedipine (D) Nitroprusside

A 73 -year-old woman is admitted to the intensive care unit following an acute A 73 -year-old woman is admitted to the intensive care unit following an acute ischemic stroke in the left parietal cortex. She has a long history of hypertension, peripheral vascular disease, chronic kidney disease, and cigarette smoking. Blood pressure is 225/135 mm Hg. Serum creatinine is 2. 2 mg/d. L at admission (baseline of 2. 0 mg/d. L).

Which of the following is most appropriate for blood pressure control in this patient? Which of the following is most appropriate for blood pressure control in this patient? (A) Hydralazine (B) Labetalol (C) Nifedipine (D) Nitroprusside (E) No antihypertensive treatment

Hyperthermic emergencies • Nonexertional heat stroke – fever above 105, • • hot dry Hyperthermic emergencies • Nonexertional heat stroke – fever above 105, • • hot dry skin, and CNS dysfunc (children left in cars) Body has huge capacity for heat dissipation (2 ml of sweat results in a kilocal of heat loss. Humans can produce 2 l per hour) Heatstroke shares pathophys of sepsis – activation of clotting, inhibition of endogenous fibrinolysis, generation of proinflammatory cytokines like TNF and IL - 1

Hyperthermic emergencies • Exertional heat stroke – high fever, (105), hot dry skin, cns Hyperthermic emergencies • Exertional heat stroke – high fever, (105), hot dry skin, cns dysfunction in setting of physical exertion • vigorous physical activity in a hot humid environment • Rhabdo more likely, dehydration

Hyperthermic emergencies • Temps above 104 (40 C) are life threatening. • Brain death Hyperthermic emergencies • Temps above 104 (40 C) are life threatening. • Brain death begins at 106 (41 C) • First sign is absence of sweating, warm dry skin • Above 105 LOC, muscle rigidity, seizure, rhabdo, DIC • Death above 113

Hyperthermic emergencies malignant hyperthermia - excessive heat generation - resulting from dysfunctional Ca channels Hyperthermic emergencies malignant hyperthermia - excessive heat generation - resulting from dysfunctional Ca channels in skeletal m Genetic predisposition Precipitated by exposure to halogenated inhalational anesthetics and/or depolarizing NM blockers (halothane and suc) More common in younger people Dx: muscular rigidity, fever (41 -45 C) rapid rise, acidosis, tachy, tachypnea, arrhythmias, mottling, rhabdo, massive increase in metabolic rate, tissue hypoxia RX: stop exposure, dantrolene (inhibits Ca release from sarcoplasmic reticulum

A 15 year old boy sustained pulmonary contusions and multiple fractures of the ribs A 15 year old boy sustained pulmonary contusions and multiple fractures of the ribs and lower extremities in a car accident approximately 12 hours ago. Open reduction and internal fixation of the femoral and tibial fractures were required and general anesthesia was administered without complications.

On physical examination in the ICU, the patient is confused and tachypneic. His temperature On physical examination in the ICU, the patient is confused and tachypneic. His temperature is 40. 0 C (104. 0 F), pulse rate is 130 per minute, respirations are 38 per minute and blood pressure is 100/70 mm Hg. His skin is mottled. His arms are diffult to flex or extend.

Laboratory Studies Serum creatine kinase Serum calcium Serum potassium Arterial blood studies 1500 U/L Laboratory Studies Serum creatine kinase Serum calcium Serum potassium Arterial blood studies 1500 U/L 10. 2 mg/d. L 5. 7 m. Eq/L (with pt. breathing 50% oxygen by face mask) PO 2 PCO 2 p. H 150 mm Hg 7. 21

Which of the following should you administer now? (A) Glucose and insulin (B) Dantrolene Which of the following should you administer now? (A) Glucose and insulin (B) Dantrolene (C) Propranolol (D) Nitroglycerin (E) Sodium bicarbonate

Hyperthermic emergencies • Neuroleptic malignant syndrome – drug associated • • • hyperthermic syndrome Hyperthermic emergencies • Neuroleptic malignant syndrome – drug associated • • • hyperthermic syndrome characterized by fever, muscle rigidity, altered mentation, pulm dynfunction and autonomic instability Differential includes thyroid storm, heatstroke, tetanus, pheo, Li toxicity, MAO crisis, serotonin syndrome Etiology involves some combination of drug induced changes in dopamine levels in brain and skeletal m. Usually caused by antipsychotics, not a clear dose-risk relationship, can be seen in antipsychotic withdrawal or withdrawal of anti. Parkinson meds No rigid criteria for diagnosis – fever, rigidity, extrapyramidal symptoms, rhabdo Rx: stop drug, fluids, dantrolene, bromocriptine

Hyperthermic emergencies • COOL…………fans, cooling blankets, cold IV fluids, cold lavage, control shivering • Hyperthermic emergencies • COOL…………fans, cooling blankets, cold IV fluids, cold lavage, control shivering • Combine convection and evaporation • Spray with water and use fan

Hypothermia • Core temp of less than 95 F or 35 C • Caused Hypothermia • Core temp of less than 95 F or 35 C • Caused by medications that alter perception of cold, increase heat loss through vasodilation, inhibit heat generation • Seen in adrenal insuf, hypoglycemia, myxedema, hypopit, sepsis, DKA, malnutrition, burns and spinal cord injuries

Hypothermia • Cardiac – Osborn wave, increased HR and BP initially and • • Hypothermia • Cardiac – Osborn wave, increased HR and BP initially and • • • then as temp falls they decrease, myocardial instability Neuro – decrease resp drive, lethargy, confusion, coma, deep tendon reflexes disappear, pupils become fixed Renal – cold diuresis, volm depletion Resp – drive decreases, resp acidosis, curve shifts to left Heme – hemoconcentration, increased WBC, low plts, impaired clotting Rhabdo, hyperglycemia, pancreatitis, ileus, dvt

Hypothermia • Overly aggressive RX kills people • Gentle handling, rewarming, close observation, search Hypothermia • Overly aggressive RX kills people • Gentle handling, rewarming, close observation, search for underling ds • Stay away from the heart with lines • Warm fluids, gastric lavage, cover head and neck, blankets, warm air • Temp greater than 85 (29 C) before death is declared

Nutrition • Pts in ICU require 25 -30 kcal/kg/day and 1 -1. 5 • Nutrition • Pts in ICU require 25 -30 kcal/kg/day and 1 -1. 5 • • protein. Calories should not come from protein Monitor prealbumin Oral feeding always preferred TPN usually 70% dextrose and 30% lipid calories. Associated with increased infection, gut mucosal atrophy and translocation of gut bacteria Immunonutrition MAY be beneficial

A 51 -year-old man is in the intensive care unit because of sepsis and A 51 -year-old man is in the intensive care unit because of sepsis and multiple organ system failure following colonic resection for a ruptured diverticulum five days ago. Infected peritoneal fluid was drained from the abdominal cavity during surgery. The patient weighs 80 kg (176 lb). He is tolerating enteral nutrition with a standard commercial preparation (1 kcal/m. L), 10 m. L/hr.

 Which of the following should you order next? (A) Advance the current nutritional Which of the following should you order next? (A) Advance the current nutritional preparation, as tolerated (B) Change to an enhanced preparation of glutamine, arginine, antioxidant, and omega-3 fatty acids (C) Begin supplemental total parenteral nutrition (D) Add daily parenteral administration of lipid suspension

Poisonings and Overdoses • Acetominophen – Usually fatal does exceeds 140 mg/kg – P Poisonings and Overdoses • Acetominophen – Usually fatal does exceeds 140 mg/kg – P 450 system converts less than 5% to reactive metabolites which are then detoxified by glutathione – Massive OD overwhelms the glutathione supply – Ethanol, BCP, phenobarb predisposes to toxicity

Poisonings and Overdoses • Acetaminophen -symptoms are initially minimal – n/v – then RUQ Poisonings and Overdoses • Acetaminophen -symptoms are initially minimal – n/v – then RUQ pain and oliguria in a few days. Transaminases peak and hepatic necrosis follows in 3 -5 days. Poor prognostic factors include late presentation, coagulopathy, metabolic acidosis, renal failure, cerebral edema – N-acetylcysteine is drug of choice – load of 140 mg/kg then 17 doses of 70 mg/kg q 4 – Charcoal OK – Use nomogram – Watch for hypoglycemia

Poisonings and Overdoses • Salicylates – rare but 1/3 die before leaving the ED, Poisonings and Overdoses • Salicylates – rare but 1/3 die before leaving the ED, lethal dose 10 -30 gms – Altered MS, tinnitus, hypoxia, hyperosmolarity, hyperthermia, seizures – Direct cns stim and resp alk with compensatory renal wasting of sodium – Metabolic acidosis (increased AG) – Pulm edema – May also see metabolic alk secondary to n/v

Poisonings and Overdoses • Salicylates – risk of bleed secondary to inhibition of prothrombin, Poisonings and Overdoses • Salicylates – risk of bleed secondary to inhibition of prothrombin, plt function impairment and gastric mucosa irritation – Give vit k, plts and FFP – Oil of wintergreen has very high amt of salicylate (1 tsp =20 tabs) – Rapidly absorbed so gastric evacuation does not usually help – Bicarb may lower toxicity and promote excretion – Development of worsening acidosis (sedation and MV) – Can lead to a quick decline – Dialysis

Poisonings and Overdoses • Stimulants – Direct cns toxicity or catecholamine release – Present Poisonings and Overdoses • Stimulants – Direct cns toxicity or catecholamine release – Present with aggitation, HTN, tachycardia, mydriasis, warm moist skin – PCP – nystagmus – Ecstacy – hyperthermia, jaw clinching – Cocaine – cardiac ischemia – Nonspecific care, fluids. Haldol, benzos for HTN, careful is using B blocker alone (unopposed alpha)

Poisonings and Overdoses • Ethanol – Coma with levels higher than 300 mg/dl – Poisonings and Overdoses • Ethanol – Coma with levels higher than 300 mg/dl – Death about 600 mg/dl – Supportive therapy, thiamine, lytes, dialysis rarely needed

Poisonings and Overdoses • Alcohol withdrawal – Symptoms within 36 hours of last drink Poisonings and Overdoses • Alcohol withdrawal – Symptoms within 36 hours of last drink but may be delayed – DTs should be managed in ICU – Fever (r/o infection), tachycardia, HTN – Npo, benzos

Poisonings and Overdoses • Methanol – Formic acid and formaldehyde – Found in windshield Poisonings and Overdoses • Methanol – Formic acid and formaldehyde – Found in windshield de icing fluid, solid fuel – 30 ml is toxic – Optic neuritis and blindness – Acidosis with anion and osmolar gaps – Any CNS finding can be seen

Poisonings and Overdoses • Ethylene glycol – Toxic metabolites – oxalic, glycolic, and glycolic Poisonings and Overdoses • Ethylene glycol – Toxic metabolites – oxalic, glycolic, and glycolic acid – Found in antifreeze – 100 ml toxic – Cns symptoms – More CV features (tachycardia, HTN, pulm edema), renal failure – Acidosis, with gaps

Poisonings and Overdoses • Treatment – Remove remaining drug from stomach – Prevent formation Poisonings and Overdoses • Treatment – Remove remaining drug from stomach – Prevent formation of toxic metabolites – Remove parent drug from circulation – Treat acidosis – Use ethanol fomepizole or 4 methylpyrazole – dialysis

Poisonings and Overdoses • Isopropyl alcohol – Intoxication and ketotic breath – Gastritis – Poisonings and Overdoses • Isopropyl alcohol – Intoxication and ketotic breath – Gastritis – Osmolar gap but no anion gap – dialysis

Poisonings and Overdoses • CO Poisoning – Vehicle exhaust, natural gas heating, inhaled smoke, Poisonings and Overdoses • CO Poisoning – Vehicle exhaust, natural gas heating, inhaled smoke, propane – Shifts curve to the left – Headache, n/v, progresses to chest pain, difficulty thinking, disorientation, weakness, delayed neurophychiatric syndrome occurs 340 days after recovery – Pulse ox overestimates arterial oxygenation

Poisonings and Overdoses • Benzos – Potentiated by ethanol and opiates – Depressed consciousness Poisonings and Overdoses • Benzos – Potentiated by ethanol and opiates – Depressed consciousness and respiration – Supportive treatment – Flumazinil is a competitive receptor antagonist that reverses resp depression – Duration of action is shorter than that of the benzo – May ppt withdrawal symptoms

Poisonings and Overdoses • Barbiturates – Potent vasodilators, cause sedation, and depressed respiration, negative Poisonings and Overdoses • Barbiturates – Potent vasodilators, cause sedation, and depressed respiration, negative inotrope, profound cns depression – Supportive therapy – Evacuation of stomach, protect airway – Those with underlying liver disease most prone to toxicity

Poisonings and Overdoses • Opioids – Depressed consciousness – Resp failure, aspiration is a Poisonings and Overdoses • Opioids – Depressed consciousness – Resp failure, aspiration is a common complication – Hypothermia, decreased gut motility, noncardiogenic pulm edema, seizures – Supportive therapy, intubation, gastric lavage – naloxone

Poisonings and Overdoses • Digitalis – hyperkalemia and arrhythmia – Treat with charcoal, fix Poisonings and Overdoses • Digitalis – hyperkalemia and arrhythmia – Treat with charcoal, fix lytes, atropine and pacing for severe bradycardia, lidocaine and dilantin for ventricular arrthymias – Digibind – cannot follow assay any longer • B blocker and Ca channel – Bradycardia and hypotension – Ca, glucagon, atropine, insulin infusion

Poisonings and Overdoses A 45 year old college professor is brought to the ED Poisonings and Overdoses A 45 year old college professor is brought to the ED after he took an overdose of propranolol. After endotracheal intubation and orogastric lavage, he receives activated charcoal, 2 liters of normal saline, atropine, and an isoproterenol drip. On arrival in the ICU, his temperature is 37. 6 C (99. 7 F), pulse rate is 48 per minute, respirations are 14 per minute (on the ventilator) and blood pressure is 70/40 mm Hg.

Poisonings and Overdoses Which of the following should you do next? (A) Increase isoproterenol Poisonings and Overdoses Which of the following should you do next? (A) Increase isoproterenol (B) Start dopamine (C) Arrange for hemodialysis (D) Infuse sodium bicarbonate (E) Infuse glucagon

Poisonings and Overdoses • TCA – Anticholinergic signs – Hot as a hare, blind Poisonings and Overdoses • TCA – Anticholinergic signs – Hot as a hare, blind as a bat, dry as a bone, red as a beet and mad as a hatter – Ileus – EKG shows QRS complex beyond 0. 12 sec, QTc and PR lengthened – Observe 12 hrs after EKG nml – Bicarb, lidocaine, NE for low BP

Poisonings and Overdoses • Serotonin reuptake inhibitors – Fever, confusion, restlessness, shivering, nausea – Poisonings and Overdoses • Serotonin reuptake inhibitors – Fever, confusion, restlessness, shivering, nausea – May see cns effects, rhabdo – Supportive therapy, cooling, benzos for seizure

A 29 -year-old woman is brought to the emergency department after she was evacuated A 29 -year-old woman is brought to the emergency department after she was evacuated from the smoke-filled second floor of her house. The fire was started by a kerosene heater on the first floor. The patient is unconscious, but the pupils are responsive, and she spontaneously moves her arms and legs. Temperature is 37. 3 C (99. 2 F), pulse rate is 135 per minute, respirations are 26 per minute, and blood pressure is 130/75 mm Hg. While the patient breathes 100% oxygen by face mask, arterial blood p. H is 7. 18, PCO 2 is 28 mm Hg, and PO 2 is 595 mm Hg. Arterial oxygen saturation by co-oximetry is 57%; carboxyhemoglobin is 43%. No trauma or burns are noted. No soot is present in the mouth or nostrils. A soft systolic murmur is heard. The lungs are clear, and the abdomen is soft.

Hemoglobin is 12. 9 g/d. L, leukocyte count is 7200/μL (80% segmented neutrophils, 8% Hemoglobin is 12. 9 g/d. L, leukocyte count is 7200/μL (80% segmented neutrophils, 8% band forms, 9% lymphocytes, 3% monocytes), and platelet count is 195, 000/μL. Serum electrolytes show an anion gap metabolic acidosis. Chest radiograph is normal. The patient is admitted to the intensive care unit and is intubated; FIO 2 is 1. 0. Your institution does not have a hyperbaric chamber, but a hospital 15 minutes away has such a facility.

 Which of the following should you do? (A) Continue current care (B) Administer Which of the following should you do? (A) Continue current care (B) Administer 100% oxygen by endotracheal tube for two to four hours; if the patient’s condition does not improve, transfer for hyperbaric oxygen therapy. (C) Administer methylene blue; if the patient’s condition does not improve, transfer for hyperbaric oxygen therapy. (D) Transfer immediately for hyperbaric oxygen therapy.

Poisonings and Overdoses A 34 -year-old woman is brought to the emergency department following Poisonings and Overdoses A 34 -year-old woman is brought to the emergency department following a suicide attempt. Three hours ago, she ingested 12 tablets (2100 mg) of glyburide. Plasma glucose is 15 mg/d. L. She is intubated and treated with multiple 50 -m. L doses of 50% dextrose in 50 m. L of water (D 50 W), 50 g of activated charcoal by nasogastric tube, and three intravenous bolus doses of diazoxide.

Poisonings and Overdoses Plasma glucose has decreased from 140 mg/d. L on admission to Poisonings and Overdoses Plasma glucose has decreased from 140 mg/d. L on admission to the ICU to 52 mg/d. L. You order administration of additional D 50 W. Which of the following medications is most appropriate to inhibit further insulin release in this patient? (A) Epinephrine (B) Glucagon (C) Hydrocortisone (D) Metoprolol (E) Octreotide

Poisonings and Overdoses A 30 -year-old healthy worker was rescued from a fire in Poisonings and Overdoses A 30 -year-old healthy worker was rescued from a fire in a plastics factory. Emergency medical teams quickly arrived and found the patient comatose; his pulse rate was 60 per minute with frequent ventricular premature complexes, respirations were 22 per minute, and blood pressure was 80/40 mm Hg. Administration of 100% oxygen, intravenous fluids, and dopamine did not change his vital signs. The patient was transported to the hospital within 15 minutes of rescue.

Poisonings and Overdoses On admission to the intensive care unit (ICU), the patient is Poisonings and Overdoses On admission to the intensive care unit (ICU), the patient is comatose. Temperature is 36. 0 C (96. 8 F), pulse rate is 105 per minute, and blood pressure is 100/60 mm Hg. She is receiving mechanical ventilation in the assist-control mode with a set rate of 16 breaths/min and FIO 2 of 0. 30; arterial oxygen saturation is 98% measured by pulse oximetry.

Poisonings and Overdoses Initial laboratory tests reveal arterial blood PO 2 is 360 mm Poisonings and Overdoses Initial laboratory tests reveal arterial blood PO 2 is 360 mm Hg, PCO 2 is 32 mm Hg, and p. H is 7. 30; carboxyhemoglobin is 15%. While preparations are being made to administer hyperbaric oxygen therapy, which of the following should you now administer? (A) Methylene blue (B) Sodium thiosulfate (C) Glucagon (D) N-acetylcysteine (E) Nitric oxide

Poisonings and Overdoses Which of the following is characteristic of nitroprusside toxicity? (A) Metabolic Poisonings and Overdoses Which of the following is characteristic of nitroprusside toxicity? (A) Metabolic alkalosis (B) Elevated plasma glucose level (C) Elevated serum creatinine level (D) Elevated arterial oxygen saturation (E) Elevated mixed venous oxygen saturation

Poisonings and Overdoses A 20 year old man is brought into the ED because Poisonings and Overdoses A 20 year old man is brought into the ED because of unresponsiveness. His family gives you a half empty bottle of amitriptyline; the prescription has been filled this morning. On physical examination, his pulse rate is 65 per minute and blood pressure is 90/50 mm Hg. His skin is hot and dry. Arterial blood studies show PO 2 is 80 mm Hg, PCO 2 is 35 mm Hg and p. H is 7. 20. Electrocardiogram discloses a QRS interval of 0. 14 second.

Poisonings and Overdoses Which of the following should you administer first? (A) Diazepam (B) Poisonings and Overdoses Which of the following should you administer first? (A) Diazepam (B) Sodium bicarbonate (C) Atropine (D) Flumazenil (E) Physostigmine

Vent Bundle • PUD prophylaxis • HOB 30 degrees • DVT prophylaxis • Daily Vent Bundle • PUD prophylaxis • HOB 30 degrees • DVT prophylaxis • Daily sedation vacation • Weaning trial

Central line bundle • Chlorhexidine • Full body drape • Masks, hats gown Central line bundle • Chlorhexidine • Full body drape • Masks, hats gown

The Society of Critical Care Medicine, American Thoracic Society, American College of Clinical Pharmacy, The Society of Critical Care Medicine, American Thoracic Society, American College of Clinical Pharmacy, and Centers for Disease Control and Prevention guidelines regarding intravascular catheter-related infections define category IA recommendations as "strongly supported by well-designed experimental, clinical, or epidemiologic studies. " Based on these guidelines, which of the following is a category IA recommendation? (A) Catheter tips should not be cultured routinely (B) Strict use of gloves and sterile technique decreases the need for hand washing (C) Guidewires can be used to exchange catheters suspected, but not proven, to be infected (D) Topical antibiotic ointment or cream should be used at insertion sites (E) Skin should be disinfected with acetone before catheter insertion

Which of the following central venous catheter sites has the lowest combined risk for Which of the following central venous catheter sites has the lowest combined risk for infection and thrombosis? (A) Femoral vein (B) Internal jugular vein (C) Subclavian vein

Rhabdomyolysis • Caused by skeletal muscle damage • Most common risk factor is ETOH Rhabdomyolysis • Caused by skeletal muscle damage • Most common risk factor is ETOH abuse • Crush injury, drugs, toxins, infection • Muscle pain, weakness and dark urine • Myoglobin is rapidly cleared so may not see it in urine • Hypovolemia, renal failure • Fluids, diuretics, bicarb

A 65 -year-old man who has diabetes mellitus, hypercholesterolemia, and hypertension is admitted to A 65 -year-old man who has diabetes mellitus, hypercholesterolemia, and hypertension is admitted to the cardiac care unit following coronary artery revascularization surgery. He has a 40 -pack-year history of cigarette smoking. Which of the following interventions has been reported to improve this patient's overall in-hospital mortality? (A) Maintaining plasma glucose level of 80– 110 mg/ d. L (B) Administration of a nebulized beta agonist (C) Administration of a beta blocking agent (D) Administration of an angiotensin-converting enzyme inhibitor (E) Administration of clopidogrel

A 30 -year-old man comes to the emergency department because of hemoptysis and severe A 30 -year-old man comes to the emergency department because of hemoptysis and severe shortness of breath; he has a large left-sided pneumothorax consistent with a stab wound. He undergoes emergent tube thoracostomy and is admitted to the intensive care unit. The admitting physician subsequently sees a television news broadcast about a stabbing and recognizes the patient's photograph as the suspect who fatally wounded another man. The incident was witnessed by several onlookers who positively identified the killer. Shortly after the broadcast, police officers arrive at the hospital; they do not have a court order or a search warrant.

The Health Insurance Portability and Accountability Act permits release of which of the following The Health Insurance Portability and Accountability Act permits release of which of the following information about the patient to the police? (A) HIV status (B) Results of DNA analysis (C) Blood specimens for evidentiary purposes (D) Name, type of injury, date and time of treatment, and description of physical characteristics

A 48 -year-old man is evaluated in the emergency department because of hypotension, dehydration, A 48 -year-old man is evaluated in the emergency department because of hypotension, dehydration, and obtundation. He has a history of alcoholism. Aggressive volume resuscitation is started with 0. 9% saline (2500 m. L rapidly infused during the first hour). He is transferred to the intensive care unit (ICU) because of acute pancreatitis.

In the ICU, the patient is intubated, and mechanical ventilation is started in the In the ICU, the patient is intubated, and mechanical ventilation is started in the assist-control mode with a set rate of 18 breaths/min, tidal volume of 0. 5 L, FIO 2 of 0. 40, and PEEP of 7 cm H 2 O. Peak pressure is 25 cm H 2 O, and plateau pressure is 20 cm H 2 O. The patient is lethargic but arousable. Temperature is 38. 1 C (100. 5 F), pulse rate is 115 per minute, respirations are 28 per minute and labored, and blood pressure is 100/60 mm Hg. Chest examination reveals symmetrically elevated diaphragms and bronchial breath sounds posteriorly at the bases. A grade 1/6 systolic ejection murmur is audible at the left sternal border and aortic areas without radiation. The abdomen is firm with epigastric tenderness. The urine appears dark and concentrated. Electrocardiogram is normal, and chest radiograph shows plate-like atelectasis in the supradiaphragmatic regions.

The patient's condition initially improves. However, during the next 16 hours, pulse rate increases The patient's condition initially improves. However, during the next 16 hours, pulse rate increases to 125 per minute, and blood pressure gradually decreases to 80/50 mm Hg. Central venous pressure is 19 mm Hg. Arterial blood p. H is 7. 26, PCO 2 is 38 mm Hg, and PO 2 is 60 mm Hg. Intake has exceeded output by 7500 m. L since admission.

Laboratory studies Plasma glucose Serum electrolytes: Sodium Potassium Chloride Bicarbonate Urinalysis 180 mg/d. L Laboratory studies Plasma glucose Serum electrolytes: Sodium Potassium Chloride Bicarbonate Urinalysis 180 mg/d. L 144 m. Eq/L 5. 0 m. Eq/L 100 m. Eq/L 12 m. Eq/L Dark urine; 1– 2 RBCs, 2– 4 WBCs/hpf

The patient remains deeply obtunded although no sedative medications have been given. Dopamine is The patient remains deeply obtunded although no sedative medications have been given. Dopamine is started; blood pressure increases to 100/50 mm Hg, but urine output decreases to less than 15 m. L/hr. Peak pressure is now 40 cm H 2 O, and plateau pressure is 35 cm H 2 O.

Which of the following is the most appropriate next step? (A) Insert a pulmonary Which of the following is the most appropriate next step? (A) Insert a pulmonary artery catheter (B) Measure bladder pressure (C) Discontinue saline and start sodium bicarbonate (D) Start furosemide (E) Start an insulin infusion (F) Start total parenteral nutrition

An 18 -year-old man sustains a closed head injury and is admitted to the An 18 -year-old man sustains a closed head injury and is admitted to the intensive care unit. He is receiving mechanical ventilation and has a Glasgow coma scale score of 6. According to the Brain Trauma Foundation guidelines, which of the following treatments during the first 24 hours is most likely to improve morbidity and mortality? (A) Fluid and sodium restriction to reduce cerebral edema and control intracranial pressure (B) Corticosteroids to reduce cerebral edema and control intracranial pressure (C) Prophylactic mannitol to reduce cerebral edema and control intracranial pressure (D) Hyperventilation to reduce intracranial pressure (E) Isotonic or hypertonic crystalloid to maintain mean arterial pressure greater than 90 mm Hg

The fiduciary relationship between physician and patient is based on the ethical principles of The fiduciary relationship between physician and patient is based on the ethical principles of autonomy, beneficence, and which of the following? (A) Altruism (B) Entitlement (C) Distributive justice (D) Non-malfeasance (E) Risk management

A 20 -year-old black man who has sickle cell disease is admitted to the A 20 -year-old black man who has sickle cell disease is admitted to the intensive care unit after intubation for severe respiratory distress. Three days ago, he developed a mild upper respiratory tract infection. Two days ago, he began to have pain in his back and limbs and had pleuritic chest pain that was followed by progressive shortness of breath.

On admission, he is conscious and receiving mechanical ventilation in the assist-control mode. Temperature On admission, he is conscious and receiving mechanical ventilation in the assist-control mode. Temperature is 38. 5 C (101. 3 F), pulse rate is 100 per minute, and blood pressure is 110/60 mm Hg. Examination of the chest reveals diffuse rhonchi. Examination of the heart is normal except for tachycardia.

Laboratory studies Hemoglobin 8. 1 g/d. L Leukocyte count 18, 000/μL Arterial blood studies Laboratory studies Hemoglobin 8. 1 g/d. L Leukocyte count 18, 000/μL Arterial blood studies (FIO 2 = 0. 80): PO 255 mm Hg PCO 226 mm Hg p. H 7. 45

Chest radiograph shows extensive bilateral pulmonary infiltrates. Electrocardiogram reveals sinus tachycardia. Bronchoalveolar lavage is Chest radiograph shows extensive bilateral pulmonary infiltrates. Electrocardiogram reveals sinus tachycardia. Bronchoalveolar lavage is performed; Gram stain of lavage fluid shows a few neutrophils and no organisms. In addition to treatment with intravenous hydration, narcotic analgesics, and broad-spectrum antibiotics, which of the following should be done now? (A) Begin methylprednisolone (B) Begin heparin and order ventilation–perfusion lung scan (C) Order exchange transfusion (D) Place a pulmonary artery catheter (E) Request open lung biopsy

Which of the following interventions is most likely to result in an immediate decrease Which of the following interventions is most likely to result in an immediate decrease in the elevated intracranial pressure of a patient who has an acute closed head injury? (A) Administration of dexamethasone, intravenously (B) Administration of acetaminophen through a nasogastric tube (C) Increase in mean systemic arterial pressure after volume administration (D) Decrease in minute ventilation (E) Elevation of the head from supine to 30 degrees

A 32 -year-old man was admitted to the intensive care unit four days ago A 32 -year-old man was admitted to the intensive care unit four days ago after sustaining a blunt head injury in a motor vehicle collision. He has been comatose since admission, and his current Glasgow coma score is 6 T (intubation and mechanical ventilation). He is being treated for ventilator-associated pneumonia and acute kidney failure secondary to rhabdomyolysis.

With the patient breathing 50% oxygen by mechanical ventilation, arterial blood p. H is With the patient breathing 50% oxygen by mechanical ventilation, arterial blood p. H is 7. 34, PCO 2 is 38 mm Hg, and PO 2 is 62 mm Hg. An intraparenchymal fiberoptic (Camino) catheter is in place; intracranial pressure has increased to 28 cm H 2 O from 15 cm H 2 O. Neurologic examination is unchanged except for unilateral pupillary dilatation. Blood urea nitrogen is 80 mg/d. L, and serum creatinine is 2. 2 mg/d. L.

In addition to hyperventilation as a temporizing measure, which of the following should you In addition to hyperventilation as a temporizing measure, which of the following should you do next? (A) Induce hypothermia to 33. 0 C (91. 4 F) (B) Administer mannitol (C) Administer methylprednisolone (D) Begin hemodialysis (E) Refer for emergency craniectomy

A 45 -year-old man who was recently treated for small cell lung cancer is A 45 -year-old man who was recently treated for small cell lung cancer is admitted to the intensive care unit because of acute shortness of breath and severe chest pain. Chest radiograph shows remarkable shrinkage of the previously large mass in his left hemithorax. Arterial blood studies (with the patient breathing 60% oxygen by face mask) reveals PO 2 is 48 mm Hg, PCO 2 is 25 mm Hg, and p. H is 7. 50. Pulmonary arteriogram shows large clots bilaterally in the pulmonary circulation. Morphine is administered to control the patient's pain. He soon begins to tire, and he requires intubation and mechanical ventilation.

The patient has a living will that states that he does not want The patient has a living will that states that he does not want "heroic measures, " including mechanical ventilation, but he does wish to receive the continued support of his physicians. You explain the potential reversibility of his acute problem, but he still refuses intubation. You believe that he is mentally competent. He is still in pain.

Which of the following should you do now? (A) Administer additional morphine and oxygen Which of the following should you do now? (A) Administer additional morphine and oxygen (B) Discontinue morphine (C) Discontinue oxygen and other support (D) Restrain the patient and proceed with intubation (E) Obtain a psychiatric consultation

An 82 year old woman who has emphysema is brought to the ED from An 82 year old woman who has emphysema is brought to the ED from a nursing home because of an apneic episode. An attendant observed that she was aspirating her gastrostomy feeding. She has been bedridden and unable to communicate since she had a stroke 2 years ago.

On physical examination, decubitus ulcers are present on the buttocks and contractures of the On physical examination, decubitus ulcers are present on the buttocks and contractures of the extremities are noted. Electrocardiogram demonstrates complete heart block with a ventricular rate of 45 beats/min. The patient’s son, who is her spokesman, is contacted. He says that everything should be done for her. A temporary pacemaker is implanted and she is admitted to the ICU. With the patient breathing 2 L of oxygen by nasal cannula, arterial blood PO 2 is 58 mm Hg, PCO 2 is 50 mm Hg, and p. H is 7. 32. Serum creatinine is 6. 5 mg/d. L.

During the next 5 days, urine output averages only 200 m. L daily despite During the next 5 days, urine output averages only 200 m. L daily despite a normally paced heart rate and the administration of diuretics. Serum creatinine rises to 8. 1 mg/d. L. Arterial oxygen saturation during apneic episodes falls between 73% and 76%. The patient’s son continues to insist that everything be done for his mother.

Which of the following should you do next? (A) Transfer the patient to another Which of the following should you do next? (A) Transfer the patient to another hospital (B) Ask the patient’s son for permission to implant a permanent pacemaker, intubate and perform hemodialysis (C) Tell the son that more aggressive interventions are unlikely to be of medical benefit and are not advisable for his mother (D) Do not offer to implant a permanent pacemaker, intubate or perform hemodialysis and tell the son that everything is being done (E) Obtain a court order to not attempt resuscitation for this patient