Critical Care #

Sepsis:

• First thing to go: Lactate, Cr
• First thing to get better: Lactate

Rapid Sequence Intubation (RSI) #

Sedation meds (all given as IV bolus: #

• Etomidate: 0.15-0.3mg/kg, 20-30mg usually
  • Onset 30-60sec, duration 3-5mins
  • Lowers seizure threshold?
  • Causes release of cortisol, can have rebound hypotension ˜24hrs later
  • Inhibits cortisol, caution in adrenal insufficiency
• Ketamine: 2mg/kg
  • Onset 1-2min, duration 5-15mins
  • Avoid with increased cranial pressures (closed intracranial trauma, ↑ intraoccular pressure, CAD, HTN)
• Propofol: 0.5-2mg/kg
  • Onset 9-50sec, duration 3-10mins
  • Can cause hypotension, just bolus with fluids at same time at it’ll be ok
  • Egg and soy allergies

Paralytics #

• Succinylcholine: 1.5mg/kg
  • Onset 30-60sec, duration 5-15mins
  • Don’t use if hx of malignant hyperthermia or life-threatening hyperkalemia
• Rocuronium: 1mg/kg
  • Onset 1-2mins, duration 45-70mins

Confirming Placement #

• ET tube tip should be between 2-5cm from carina.
• Examples with anatomy

Dr. Amir’s Setup #

• ETT 7.5 (7-8)
  • good for almost everyone
• Etomidate 20mg
• +/- versed 2-4mg
• Paralytic
  • Make sure you can bag before you give paralytic
    • If not, you are screwed if you give paralytic and can’t intubate
  • Rocuronium: 1mg/kg
  • Vecuronium: 10mg fixed
  • succinylcholine: 1.5mg/kg
    • Careful as can raise K, not great for renal failure Get a PEEP valve on bag mask (helps you get peep when bagging, really need this for ARDS, when you take off HHF sats will tank)

ACLS (Adult) #

Arrest #

Bradycardia #

• Eval
  • ABCs
  • O2
  • IV
  • EKG
• Stable
  • Monitor
• Unstable
  • Atropine 1mg (q3-5mins, max 3mg)
    • Epinepherine gtt: 2-10mcg/min
    • Dopamine gtt: 5-20mcg/kg/min
  • Transcutaneous pacing

Tachycardia #

• Eval
  • ABCs
  • O2
  • IV
  • EKG
• QRS complex width
  • Narrow (<0.12)
    • Stable
      • Vagal maeuvers
      • Adenosine
        • 6mg then 12mg (can go higher in real life)
    • Unstable
      • Sync cardioversion
      • Adenosine
  • Wide (>0.12)
    • Stable
      • Adenosine (only if regular and monomorphic)
      • Procainamide 20-50mg/min (max dose 17mg/kg)
    • Unstable
      • Sync cardioversion

Stroke (CVA) #

• ABCs, O2 if needed
• Check glucose
• CT/MR
• IV

Goals:

• Gen assessment: 10 mins
• Neuro assessment and CT/MR: 20 mins
• Rads read: 45mins
• lytics within: 60 mins from ED door
• lytics within: 3-4.5 hrs of symptom onset
• EVT (endovascular therapy)
  • LVO: 24 hrs
  • 0-6hrs: CT findings
  • 6-24hrs: penumbral scan
• Admission to bed: 3 hrs
• Transfers: 1 hr

AMI #

• if O2 < 90% → 4L
• ASA 162-325mg
• Nitro (careful with RV ischemia, pre-load dependent)
• Morphine IV (careful with RV ischemia, pre-load dependent)

Goals:

• Door to balloon: 90 mins
• Door to needle (lytics): 30 mins

ROSC #

• Breaths: 10+/min
• SpO2: 92-98%
• PaCO2: 35-45 mmHg
• SBP >90, MAP >65
• EKG → if STEMI or LBBB cards intervention
• Follows commands?
  • No
    • TTM (32-36C) x 24hrs
    • CT head
    • EEG
  • Yes
    • ICU management

BLS #

• Adults:
  • Breaths: 1 every 6 sec
  • 30-2
  • If pregnant to umbilicus, laterally displace uterus
• Peds:
  • Breaths: 1 every 2-3 sec
  • One rescuer
    • 30-2
    • Leave after 2 mins to get AED
  • Two+ rescuers
    • 15-2

Vent Management #

Three modes to know:

• VC
  • Good for COPD, asthma since you can control the I:E ratio
• VC+ (PRVC)
  • Pressure regulated volume control
  • Good general purpose
• APRV
  • Inverted I:E
• Oxygenation
  • FiO2
  • PEEP
• Ventilation (i.e. CO2)
  • tidal volume
  • rate
  • combination of which is your minute ventilation

EMCrit Vent Handout

Changes #

Winter’s formula: $P_{CO_2} = 1.5 * HCO3- + 8 +/- 2$

Then figure your change as CO2 is proportional to rate and tidal volume. $CO2 prop rate * V_T$

Plateau pressures should be <30

tidal volume should be 6-8cc/kg ideal body weight

Sedation on Vent #

• Important to differentiate between anxiety and delirium, sometimes hard to tell the difference

• [PADIS 2018 guidelines](’/literature/PADIS 2018 guidelines.pdf')

• Precedex

  • Awesome med, can be continued post extubation
    • Quick and clean on and off
    • Not a sedative, it’s an anxiolytic
    • Can cause bradycardia/hypotension
      • Not a huge issue, but be aware of it
  • Transition to clonidine if going to be used for more than 7 days

• Propofol

  • Great for short term (<3-4 days) as is a sedative
    • switch to fentanyl/versed pushes if you need longer
  • Quick on, quick off
  • Has some GABA activity
    • Good choice in EtOH withdrawl and/or seizures
  • Watch for propofol infusion syndrome
    • Looks like shock without a source
      • ↑ CK
      • ↑ lactate (12-14ish)
      • ↑ Chol, LFTs
      • hypotension
      • green urine (boards only really)
    • usually happens to people on high doses (>100/hr) and long durations (>3-4 days)
  • Not great in fat people, gets stored in fat

• Ketamine

  • Need to learn more here…

• Always favor narcotic pushes over drips

• Last resort is benzos

  • Almost never use benzo drips

Paralytics #

Almost always use Cisatracurium.

• Cleared by Hoffman elimination, not eliminated by kidneys or liver.

Anxiety #

• Talk to family, ask if pt with history of anxiety
• Benzos great for anxiety, crappy for delirium (can make it worse)

Delirium #

• Definition: imparied attention (that’s it!), usually acute onset (vs dementia)
  • Important as is independent risk factor for mortality
  • Evidence to suggest that it’s an inflammatory brain process (from autopsies)
    • Important for healing, not just for making out and RNs lives easier
  • Hyperactive and hypoactive flavors

Treatment #

• haloperidol (Haldol)
  • 0.5-20mg q15-30mins until calm
• olanzapine (Zyprexa)
  • 5-10mg IM, max 30mg/day
• ziprasidone (Geodon)
  • 10mg IM q2h or 20mg q4h, max 40mg/day
  • 20-40mg PO q12h
• quetiapine (Seroquel)
  • 50mg PO BID, max 400mg/day

Also Qtc prolongers

Watch for serotonin sydrome with above meds: - fever, rigitity - Check CPK,

Central Line #

• Examples of placement with anatomy

Nasogastric tube (NG/Dob-hoff) #

• Examples of placement with anatomy

ECMO #

• VV = all on right side
  • Code => normal
• VA = take from right side, return to arterial side
  • Code => just fix heart
• Sweep = speed of gas (O2) in exchanger
  • Basically equivalent to minute ventilation (think of it like resp rate on vent)
  • Increase this to take off more CO2
• FsO2 = just like FiO2
• Doing good if sweep <2, and FsO2 as low as can go

Acute hypoxia #

• Causes:
  • Parenchymal => pulm edema, atelectasis/shunt
  • PE
  • Cardiac => MI, arrhythmias
  • Hypercarbia => displaces O2

Chronic hypoxia #

• Causes:
  • CHF
  • pHTN
  • Lung disease
  • CO2
  • Shunt

Workup #

• ABG => looking at pCO2, paO2
• PFTs (full): dlCO, plus underlying lung disease
• CT => structural lung disease (CXR good quick and dirty look, but can miss a lot)
• Echo w/ bubble => cardiac causes
• EKG

Acute Respiratory Distress Syndrome (ARDS) #

• Acute onset hypoxemia with bilateral radiographic infiltrates (no LA hypertension)
  • Dx needs three things:
    1. Onset within one week of known insult
    2. Bilat opacities on CXR => not effustions, or otherwise explained
    3. Resp failure not from fluid overload or some other cause (i.e. cardiac causes)
  • Decrease in lung compliance
  • Insults usually cause direct lung injury
    • PNA
    • Aspiration
    • Massive rapid transfusion (TRALI)
    • Non-pulm sepsis
    • Severe trauma

Severity #

Evaluation #

• r/o other causes of sepsis
• ABG
• CXR/Chest CT
• Echo + pBNP (r/o cardiac causes)
• Bronch

Treatment #

• Mechanical vent

ARDSnet table #

Usually use high PEEP for COVID-19.

Airway Pressure Release Ventiliation (APRV) #

EMCrit explanation article and settings/strategy.

• Good for reqruitment
• Not great for "floppy lung" diseases (COPD, asthma)
• Best for stiff lungs (i.e. ARDS, pneumonia, some ILDs)
• Typical start
  • P-high: 30-35cm
  • P-low: zero
  • T-high: 5 sec
  • T-low: 0.5 sec
    • reduce if tidal volume >8mL/kg

ABGs #

• pCO2 normal range:
  • Men: 36-40
  • Premenopausal Women: 34-36 (even lower in pregnancy)
• pO2 normal range:
  • Denver: 70-80
• VBG
  • Tells you everything except for oxygenation
  • To “correct” to an ABG
    • Peripheral
      • pH: add 0.02-0.04
      • pCO2: subtract 3-8mmHg
    • Central
      • pH: add 0.03-0.05
      • pCO2: subtract 4-5mmHg
• SvO2
  • Normal: >65% (normal O2 extraction ≈25-30%)
  • <65% => imparied tissue oxygenation
  • >80%
    • High PaO2
    • Cytotoxic dysoxia
      • severe sepsis
      • cyanide poisoning
      • mitochrondial disease
    • Microcirculatory shunting
      • severe sepsis
      • liver failure
      • hyperthyroidism
    • Left → right shunt

Volume Status #

Assessment of volume status in criticall ill

Septic Shock #

Anaphylactic Shock #

• Epipen q5min
• Epi drip with “dirty” epi
  • “Dirty” epi
    • 1mg epi in 1000mL NS
  • Start at 1mL/min
  • Titrate to symptoms and BPs
• Adjuncts
  • Methylprednisone 125mg IV
  • Diphenphyramine 2mg/kg (50mg max)
  • famotadine 20mg IV (or other H2 blocker)

Pearls #

• Palpate posterior upper leg for edema in ICU patients (most dependent spot)
• Every 10 CO2 increase => 1 bicarb increase
• Sats above 80 are OK! As long as normal WOB, mentating normally.
• Stress Dose Steroids: Hydrocort 50mg q8h until shock gone
• Angor animi => medical term for “sense of impending doom”