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16 Critical Care
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198
Accounting
Undergraduate 1
11/26/2017

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Term
Equations:
MAP =
Definition
= CO x SVR
Term
Equations:
CO =
Definition
= HR x SV
Term
Equations:
CI =
Definition
=CO/BSA
Term
Equations:
SVR =
Definition
80 x [(MAP-CVP)/CO]
Term
% of cardiac output that goes to major organs?
Definition
Kidney 25%
Brain 15%
Heart 5%
Term
How is diastolic filling time determined? How does it affect CO?
Definition
-determined by HR
-CO increased up to 120-130 HR, then starts to dec due to inadequate filling time
Term
What is Preload directly related to?
Definition
LV end diastolic pressure
(which is related to LV EDVolume)
Term
effect of atrial contraction on LV EDV?
Definition
inc by 25%
Term
Equations:
Stroke vol
Definition
= LVEDV - LVESV
Term
Anrep effect =
Bowditch effect =
Definition
Inc myocardial contractility w/
...inc afterload
...inc HR
Term
Starling's Law =
Definition
greater the LVEDV, the greater the EF
*up to a certain point*
Term
Equations
EF =
Definition
SV/LVEDV
Term
Equations:
-O2 delivery
Definition
= CO x CaO2 x 10
*CaO2 = arterial oxygen content
*CaO2 = [Hgb x 1.34 x O2 sat + (pO2 x 0.003)]
Term
Equations
O2 consumption
Definition
= CO x (CaO2-CvO2)
CvO2 = venous O2 content
Term
what is the normal O2 delivery to consumption ratio?
Definition
4:1 (4x more O2 delivered than consumed)
*25% utilized*
*SvO2 = 75%*
Term
O2 Hgb curve
-right vs left shift factors
Definition
1. right = O2 unloading
-INC CO2, temp, ATP, 2-3DPG, H+ (dec pH)
-methemoglobinemia
2. left = hang on to O2
-opposite above, fetal Hgb, CO poisoning
Term
p50 =
Definition
O2 at which 50% fo O2 receptors are saturated
-27 mmHg
Term
most important determinant of myocardial O2 consumption?
Definition
Wall tension
(next is heart rate)
Term
Bronchial blood flow
-how does it affect blood pO2?
Definition
after supplying bronchus/lung tissue, empties into pulm veins..
-thus LV blood pO2 is 5 mmHg lower than pulm capillaries.
Term
normal A-a gradient?
Definition
10-15 mmHg
Term
Coronary sinus blood
-what is the venous O2 saturation?
Definition
30%
lowest in the body
Term
highest venous O2 saturation in body?
Definition
80%
*receives 25% of CO but has low O2 extraction*
Term
Pulse ox misread causes?
Definition
nail polish, dark skin, low CO, ambient light, low Hct, hypothermia, carbon monoxide
Term
PA cath distances to wedge?
Definition
R SVC 45 cm
R IJ 50 cm
L SVC 55 cm
L IJ 60 cm
(if much longer...either wrong place or has loop)
Term
optimal lung placement for PA cath?
Definition
Zone 3 (lower lobes)
*less resp influence*
Term
when are wedge pressures taken?
Definition
at end-expiration
Term
sign that you are PA cath in correct place?
Definition
-appearance of dicrotic notch
-inc in diastolic pressure
Term
absolute C.I. to PA cath placement
Definition
-right side endocarditis
-right sided thrombus
-right mechanical heart valve
Term
PEEP effect on wedge pressure?
Definition
IF PEEP over 10
-subtract 1/2 PEEP from wedge IF PEEP over 10
Term
normal swan #s
Definition
CO 4-8 L/min
CI = 2.5-4 L/min
SVR = 8000-1400 (1100)
wedge = 7-11
CVP 3-7
SvO2 = 75% +/- 5
Term
Hemorrhagic shock
-Dec vs Inc hemydynamic variables
Definition
Dec CVP/Wedge, SvO2, CI
Inc SVR
Term
-Dec vs Inc hemydynamic variables
Septis shock
Definition
Dec CVP/Wedge, SVR
inc CI, SvO2 (hyperdynamic)
Term
-Dec vs Inc hemydynamic variables
Cardiogenic
Definition
Dec CI, SvO2
Inc CVP/wedge, SVR
Term
-Dec vs Inc hemydynamic variables
tamponade
Definition
Dec CI, SvO2
Inc CVP/wedge, SVR
Term
-Dec vs Inc hemydynamic variables
Neurogenic shock
Definition
Dec SVR, CVP/Wedge, CI
Inc SvO2
Term
-Dec vs Inc hemydynamic variables
Adrenal insuff
Definition
Dec: CVP/Wedge, CI, SVR, SVO2
Term
-Dec vs Inc hemydynamic variables
PE
Definition
Dec CI, SvO2
Inc CVP/Wedge, SVR
Term
initial response to hemorrhagic shock?
Definition
increased diastolic pressure
Term
common early sign just before clinical sepsis?
Definition
hyperglycemia
early: impaired utilization
late: insulin resistance
Term
cardiogenic shock w/high MAP
-tx?
Definition
lasix to dec preload, pulm congestion, over-distension (which worsens contractility)
Term
Beck triad = ?
Definition
HypoTN
JVD
Muffled heart sounds
Term
First ECHO sign of tamponade?
Definition
impaired diastolic filling of RA
Term
how to be sure pericardiocentesis is pericardial blood?
Definition
pericardial blood does NOT clot
Term
sxs of neurogenic shock?
Definition
HypoTN, Bradycardia, warm extremities
-dec SVR
Term
neurogenic shock
-tx
Definition
1. give volume (CVP 8-12, wedge 16-18)
2. phenyl to raise SVR
Term
interp of ACTH stim test?
Definition
+ve cosyntropin test =
1. cortisol < 15 OR
2. change < 9
Term
tx acute adrenal insuff?
Definition
-Dexamethasone + fludrocortisone
*give these BEFORE stim test, as they don't interfere w/results*
-Volume
Term
Relative potency of different steroids?
Definition
1x = cortisone, hydrocortisone
5x = prednisone, prednisolone, Me-pred
30x = dexamethasone
Term
most potent steroid?
Definition
dexamethasone
30x cortisone
Term
MC EKG finding w/PE?
Definition
SVT
Term
possible sign of PE in intubated pt?
Definition
sudden dec in ET-CO2
-resp alkalosis due to tachypnea
Term
MC source of PE?
Definition
ileofemoral DVT
Term
% pts with PE that have negative LE duplex?
Definition
1/3
Term
heparin dose vs PE?
Definition
80 u/kg bolus
18 u/kg/hr gtt
Term
alpha 1 effects?
Definition
vasoconstrict
gluconeogen, glycogenolysis
(phospholipase medatied)
Term
alpha 2 effects?
Definition
venous vasoconstrictor
(dec cAMP = dec Ca)
Term
Beta 1 effects?
Definition
inc contractility
inc HR
(inc cAMP mediated)
Term
Beta 2 effects?
Definition
vaso/bronchodilat
inc glucagon, renin
(cAMP mediated)
Term
Dopamine effects
Definition
inc renal blood flow
?inc splanchnic flow?
Term
Vasopressin receptor location/effects?
Definition
V1 = vascular smooth muscle, constriction
V2 = collecting ducts, water resporption
V3 = endothelium, F8 and vWF release
Term
Nitric oxide precursor?
-mech?
Definition
Arginine (nitric oxide synthetase)
NO acts on guanylate cyclase to in cGMP ==>dilation of BV
Term
effects of ACE-I?
Definition
1. blocks angiotensin 2 formation
--> dec BP, dec aldost, dec Vaso release
Term
prostacyclin vs endothelin receptor on pulm function?
Definition
prostacyclin = pulm vasodilation

Endothelin = pulm vasoconstriction
Term
inotropes that direclty inc cAMP
Definition
Dopamine
Dobutamine
Epi
Isoproterenol
Term
Dopamine effect based on dose (mcg/kg/min)
Definition
Low = 1-5 = DA receptors
mid = 6-10 = beta 1+2 (contractility, HR)
high = >10 = alpha-1 vasoconstrict
Term
Dobutamine
-receptor target?
Definition
Beta-1 (contractility)
*some beta 2 (dilation) at high dose >15*
Term
Milrinone mech
Definition
-PDE inhibitor (inc cAMP = inc Ca)
*also vasodilator*
Term
good inotrope for long-term use?
Definition
Milrinone
-not subject to beta-receptor down-reg
Term
isoproterenol
-receptor targets
-SE?
Definition
Beta 1+2: inc HR, contractility + V.dilate

SE = Arrhythmogenic, inc heart metabolic demand. might actually dec BP via B2
Term
which pressors are also inotropes?
Definition
NE and epi
Term
phenylephrine
receptor target
Definition
alpha 1 (vasoconstriction)
Term
receptor target
-NE
Definition
alpha 1 + 2
some beta 1
*potent splanchnic vasocosntrictor*
Term
receptor target
epi
Definition
low dose (1-5 mcg/min) = Beta 1+2
high = >5 = alpha 1+2
*at low doses..beta 2>1 = lowers BP*
Term
epi SE
Definition
arrhythmogenic
high O2 demand
low doses: Beta 2>1 = hypotension
Term
vasopressin target?
Definition
V1 receptors
-0.01-0.1 U.min = vasoconstriction
Term
Nipride
-mech/effect
Definition
-NO mediated vasodilation (arterial>>>venous)
Term
nipride cyanide toxicity risk factors?
-what labs to get/characteristic results?
-pphys
Definition
-nipride > 3 ug/kg/min x 72 hrs
-get gas (met acid), thiocyanate level
-Inc SVO2 (L->R shunt) due to ETC disruption (cyanide binds cytochrome C)
Term
Cyanide poisoning tx?
Definition
Amytl nitrite f/b sodium nitrite
Term
Nitroglycerin
mech?
Definition
NO mediated venodilation (minimal arterial)
-dec myocardial wall tension 2/2 dec preload
Term
benefits of ACE-I post MI?
Definition
dec mortality
dec CHF development
Term
ACE-I
absolute contraindications
Definition
hx angioedema
renal artery stenosis
Term
hydralazine effect?
Definition
arterial vasodilation
Term
fenoldopam
-receptor target
-effect
Definition
DA-1A receptor
-art vasodilator (w/reflex tachy)
Term
Labetalol
-target
Definition
1st = alpha 1 blk
2nd = beta 1 block, beta-2 agonist
*dec MAP w/out altering HR/CO*
Term
Bosentan mech?
Definition
pulm vasodilation
-blocks endothelin
Term
Sildenafil mech
Definition
NO mediated pulm vasodilation
(soluble guanylate cyclase)
Term
EKG and timing of IABP?
Definition
inflation on T wave (diastole)
deflation on P wave/start of Q wave (systole)
Term
IABP location?
Definition
just distal to left Subclav artery
Term
IABP effects?
Definition
1. inc MAP (inflates during ventric diast)
2. inc coronary perfusion (Coronarys fill in diastole)
3. dec afterload (deflates during sys)
Term
IABP indications
Definition
1. cardiogenic shock s/p MI
2. vent septal ruptuer
3. acute MR (ex rupt. pap m)
4. USAngina
5. pre-op cardiac surg w/low EF
Term
IABP absolute CI?
Definition
aortic regurg
aortic dissection
severe AI occlusive DZ
(relative CI = aortic graft, aneurysm)
Term
prolonged QT
-causes
Definition
-meds: amio, fluoroquinolones, others
-lytes: hypoMG
Term
cardiac sugery post-op a-fib
-% in sinus by 6 week?
Definition
90%
Term
Afib
-AC and cardioversion rec?
Definition
LEARN IT
Term
code meds
Definition
epi 1 mg
vaso 40 units
amio 300 mg (150 mg 2nd dose)
-----
atropine 1 mg
Term
H/Ts
Definition
Hypovolemia, hypoxia, H+, Hypo/HyperK, Hypothermia

Tension ptx, Tamponade, Toxins, Thrombosis (PE), Thrombosis (coronary)
Term
Good initial step vs PEA?
Definition
give volume
Term
Q waves =
Definition
old infarct
Term
ST ele vs depression =
Definition
acute MI vs ischemia
Term
Epicardial pacer
nomenclature->what each letter means
Definition
1st letter = which chamber is paced
2nd = which chamber is sensed
3rd = response to sensed beat
Term
Epicardial pacers
DDD =
Definition
D = dual
senses both, paces both, inhibits/triggers
* i = just inhibits*
Term
epicardial pacers
-myopotential inhibition =
Definition
-sensitivity too high (picking up background noise)
-->turn sensitivity down
**pacing too much = sensitivity too low = turn it up***
Term
Which renal limb controls GFR?
Definition
efferent (leaving glomerulus)
Term
what causes renin release?
Definition
-dec pressure (sensed by JGA)
-inc Na (sensed by macula densa)
*others: beta 2 stim, hyperK*
Term
inhibition of renin release?
Definition
hypokalemia
Term
renin function?
Definition
convert angiotension to angiontensin 1
*angiotensin synth in liver*
Term
ACE
-location?
-functions
Definition
-lung
-convert ang I-->ang II
*also breaksdown bradyK*
Term
angiotensin II
-primary vs secondary effects
Definition
-primary: aldost release from adrnl cortex
-2ndry:
vasocontrict, inc symp tone, ADH release
Term
Aldosterone
-mech
Definition
1. activate Na/K ATPase @ DCT
= Na/water reab + K excretion
2. activate Na/He xchanger->H+ excretion
-->met alkalosis
Term
ADH target?
Definition
collecting ducts (water reab)
Term
ANP
-mech of release
-effects
Definition
atrial distension (vol overload) = release from atrial wall
-inhib Na/water reab @ CD
-vasodilate
-inhib renin/aldosterone production
Term
mech of kidney injury from..
1.NSAID
2.Aminoglycosides
3.dye
4.myoglobin
Definition
1. --|prostaglandin = arteriole v.constrict
2-4. direct tubule injury
Term
mech of kidney injury from..
1.NSAID
2.Aminoglycosides
3.dye
4.myoglobin
Definition
1. --|prostaglandin = arteriole v.constrict
2-4. direct tubule injury
Term
Hct inc seen from HD?
Definition
hct inc 5-8 per liter taken off
Term
Contrast dye prep protocol
Definition
1. HYDRATE (most protective measure)
2. N acetylcysteine (600 PO BID day before)
3. bicarb gtt (1 hr before-->6 hr after)
4. Hold ACE/ARB/NSAIDs/diuretics
5. minimize contrast vol, use isosmolar soln
Term
cause of MRI induced renal fail?
Definition
from gadolinium
Term
mech of myoglobin toxicity?
tx
Definition
1. converted to renal toxic metab ferrihemate in acidic env
*tx bicarb gtt (alkalinize urine) + IVF*
Term
IVF to avoid in chronic renal failure?
Definition
LR (has too much K)
*use NS*
Term
Equations
FeNa
Definition
= Urine Na/Cr / plasma Na/Cr
(ratio of urine to plasma Na/Cr)
Term
FeNa interp
Definition
Pre-renal = < 1 %

Renal = > 2%
Term
labs suggesting pre-renal etiology/
Definition
FeNa<1%
Urine Na < 20
BUN/Cr > 20
Urine osm > 500 mOsm (concentrated)
Term
MCC renal ATN in peri-op settings?
Definition
intra-op hypoTN
Term
Tx ATN?
Definition
?
Term
MCC..
-poor post-op UOP
-post-op ARF
Definition
Hypovolemia

HypoTN-->ATN
Term
Pulm Function tests
TLC =
Definition
total lung capacity = FVC + RV
Term
FVC =
Definition
Forced vital capacity
-vol of air w/max exhalation after max inhalation
Term
Residual volume =
what % of lung volume does it account for?
Definition
vol after max expiration
= 20% of lung volume
Term
FRC =
Definition
functional residual capacity
= lung vol after normal exhale
= ERV + RV
Term
What causes dec FRC?
Definition
atelectasis
ARD
contusion
Term
ERV =
Definition
exp reserve vol = volume of air expired AFTER normal expiration
Term
insp capacity =
Definition
vol of air inhaled after normal exhale
Term
FEV 1 =
Definition
forced exp vol in 1 second after max inhale
Term
minute ventilation equation =
Definition
tidal volume x RR
Term
lung compliance equation =
Definition
change in lung vol/change in lung pressure
Term
area of highest V/q ratio?
Definition
upper lung
Term
dead space definition
-normal vol?
Definition
lung that is ventilated but not perfused
-150 cc
Term
causes of inc dead space
Definition
-dec Cardiac output = capillary collapse
-PE, pulm HTN, ARDS (cap compression)
-Excessive PEEP (cap compessed)
Term
reflection of inc dead space on labs?
Definition
inc pCO2
Term
V/Q mismatch definition
Definition
poor ventilation but GOOD perfusion
Term
VQ mismatch causes
Definition
MCC = atelectasis
ARDS
Term
Lung volumes
-restrictive vs obstructive pattern
Definition
Restrictive: dec TLC, RV, FVC

Obstructive: Inc TLC, RV. Dec FEV1
Term
Lung volumes
Changes w/obesity?
Definition
Dec FVC, FEV1, FRC
Term
pulm vasoconstrictors?
Definition
hypoxia
acidosis
histamine, serotonin, thromboxane
epi, NE
Term
causes of pulm shunting
Definition
nipride, nitroglycerin, nifedipine
-->manifests as hypoxia
Term
Normal IE ratio?
-vent changes w/ARDS?
Definition
1:3
inc I time with ARDS to improve oxygenation
Term
pphys of fever w/atelectasis?
Definition
IL-1 release from pulm macrophages
Term
how does inc PEEP increase oxygenation?
Definition
by improving FUNCTIONAL RESIDUAL CAPACITY
*better at improving pO2 than inf FiO2*
Term
FiO2 goal to dec O2 radical tox?>
Definition
< 60%
Term
hemodynamic effects of inc PEEP?
Definition
dec CO 2/2..
dec RA filling
inc pulm vascular resistance ->dec LA filling
Term
how does pressure support work?
Definition
dec work of breathing
-inspiratory pressure held constant until minimum tidal volume met
Term
how to prevent barotrauma?
Definition
keep plateau pressure < 30 (most impt)
keep peak pressure < 50
Term
extubation parameters
Definition
1. neg insp force > 20
2. FiO2 < 40, PEEP 5, PS 5
3. Rapid shallow breathing index < 105
*RR/TV*
*>105 -->95% fail*
Term
laryngeal edema mgmt
Definition
MePred 20 mg IV q 12 before ext
-check for airleak
Term
preload changes with mechanical ventilation?
Definition
inspiratoin = dec BP 2/2 dec venous return
-SVC + IVC compression (dec RA return)
-pulm cap compression (dec LV preload)
**OPPOSITE OF NORMAL PHYSIO**
Term
common scenario for use of high freq ventilation?
Definition
in peds..
TE fistula, BP fistula
Term
pphys COPD?
Definition
1. parenchymal damage/small airway collapse
-->air trapping
2. chronic bronchitis
Term
tx found to inc COPD survival long term?
Definition
O2
Term
Auto-PEEP definition?>
Definition
interruption of expiration before alveolar pressure falls to pATM
Term
heart effects of COPD?
Definition
RV hypertrophy/dysfunction
-cor pulmonale
Term
normal % of VO2 accounted for by work of breathing?
Definition
2%
Term
COPD exac tx?
Definition
-O2, nebs, inhaled steroids +/- PO/IV
-amoxicillin
-NIPPV
Term
best esophagectomy approach in pt with bad COPD?
Definition
trans-hiatal
-avoid thoracotomy
Term
MCC ards
Definition
direct: pna 40%, asp 15%
indirect: MCC sepsis
Term
ARDS criteria
Definition
1. acute
2. bilateral diffuse patchy CXR
3. Wedge < 18
4. PO2/FiO2 < 300
Term
ARDS Bronch finidngs
Definition
-proteinaceous exudate (not diagnostic)
Term
ARDS IE ratio changes?
Definition
increase I time
-increases oxygenation at expense of PERMISSIVE HYPERCAPNEA
Term
general ARDS gas goals?
Definition
pH>7.3
PO2 > 60, Sat > 92
permissive hypercapnea
tidal vol 6-8 cc/kg
P plateau < 30
Term
VAP criteria?
Definition
new infiltate, Fever, purulent sputum
*>48 hrs on vent*
Term
-Mediators of SIRS?
-most potent SIRS stimulator?
Definition
TNF-alpha, IL-1
*GNR endotoxin (lipid A portion of lipopolysaccharide) = most potent stimulator**
Term
most potent TNF alpha trigger?
Definition
Lipid A portion of LPS endotoxin
Term
Air embolus sxs?
Definition
Mill wheel murmur
sudden dec ET-CO2, hypoTN, tachy
Term
Air embo tx?
Definition
trendelenburg, left lateral decub (keep it in right heart)
-
Term
classic fat embo sxs?
Definition
-petechiae, hypoxia, AMS
-sudan red stain: fat in sputum, urine
Term
MCC fat embo?
Definition
LE fx/ortho surg
-hip/femur
Term
MC timing of ICU delirium ?
Definition
MC after POD3
Term
factors that preclude brain death dx?
Definition
-Uremia
-Temp <32
-hypoTN < 70/40
-desat w/apnea test
-drugs/meds/metabolic issues
Term
requirements for brain death dx?
Definition
-2 physician exams
-silent EEG
-MRA with no flow
-6 to 12 hours of...
1. no pain response
2. no cold oculovestibular reflex
3. no oculocephalic reflex (dolls eye)
4. +ve apnea test
5. no corneal reflex
6. no gag reflex
7. fixed, dilated pupils
Term
how to perform/interp apnea test?
-when to terminate test?
Definition
1. Pre-oxygenate, then disconnect from vent
2. +ve if CO2>60 OR inc bhy 20
**terminated if Psys<60 or desat**
Term
exam finding still +ve with brain death?
Definition
deep tendon reflex
Term
Abd compartment syndrome bladder pressure/
Definition
>20
Term
gout dx?
Definition
needle shaped negatively birifringent crystals
Term
gout tx?
Definition
-acute: indomethacin, cochicine, naproxen, steroids
-
Term
QT interval
-normal values vs abn/
Definition
-prolonged= >440ms men, >460ms in women
*QTc> 500 = inc risk of torsades
*QTc is abn short if < 350ms
Term
PPhys of carbon monoxide poisoning/
Definition
CarboxyHgb has 250x affinity for Hgb vs O2
=left shift @ dissociation curve
Term
Carbon monoxide poisoning
-dx
tx
Definition
-falsely elevated sat
-carboxyHgb levels >10% (>20% in smokers)
*tx = 100% O2 +/- hyperbaric O2*
Term
Methemoglobinemia pphys
Definition
1. O2 carrying Fe2+ (ferous)
2. oxidized to Fe3+ (ferric) = methemoglobin ==>right shift = O2 cant bind
Term
Methemoglobinemia
1. causes
2. sxs
3. tx
Definition
1.causes: benzocaine (hurrcaine spray), dapsone, fertilizers
*ALL = OXIDIZING AGENTS*
2. low O2 sat of 85%
3. O2 + MeBlue (1mg/kg-->restores Fe to ferrous/reduced state)
Term
Critical illness polyneuropathy
-sxs
-rf
-clinical sig in ICU
Definition
-motor>sensory
-RF = ARDS, sepsis, steroids, SIRS, paralytics, hyperglycemia
*can -->diffiuclty weaning*
Term
enzyme that forms O2 radicals?
Definition
xanthine oxidase
-endothelial cells
*normally metabolized purines->uric acid*
Term
physio variables inc w/CO2 pneumoperitoneum?
Definition
-pulm art pressure, pulm vasc resistance
-HR
-SVR, VCP, Mean airway presure, PIP,
-CO2 (can dec contractility)
Term
physio variables dec w/CO2 pneumoperitoneum?
Definition
-pH, venous return, renal flow
-cardiac output
Term
Technology
-US modes
Definition
B mode = brightness (assess relative density)
Duplex = B mode + doppler
Term
US freq and best use?
Definition
lower freq = deep structures, less resolution
Term
Harmonic scalpel
-how it works?
Definition
disrupt protein hydrogen bonds
Term
Argon beam
-mech?
-good use?
Definition
causes superficial coagulation
-is non-contract-->use for liver/spleen
Term
CO2 laser
-max depth ?
Definition
0.5 mm
(wear mask if used vs condylomata ccuminata)
Term
incidence of injury w/Verres?
Definition
0.1%
Term
Gortex vs Dacron
-major difference/
Definition
Gortex DOES NOT allow fibroblast in-growth
*Dacron Does*
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