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4/20/2015
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Question: Question: A. It will be 10 mmHg
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5‐10 mmHg Weinberger SE. Principles of Pulmonary Medicine, 4th ed. Philadelphia, Elsevier Science, 2004.
Question: Question: C. Hypoventilation
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A‐a Gradient will be normal in both these cases
Weinberger SE. Principles of Pulmonary Medicine, 4th ed. Philadelphia, Elsevier Science, 2004.
Weinberger SE. Principles of Pulmonary Medicine, 4th ed. Philadelphia, Elsevier Science, 2004.
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Weinberger SE. Principles of Pulmonary Medicine, 4th ed. Philadelphia, Elsevier Science, 2004.
Weinberger SE. Principles of Pulmonary Medicine, 4th ed. Philadelphia, Elsevier Science, 2004.
Question: 5
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Question: D. Noninvasive Positive Pressure Ventilation (NPPV)
Khilnani GC, Banga A. Noninvasive ventilation in patients with chronic obstructive airway disease. Int J Chron Obstruct Pulmon
Dis. 2008;3(3):351‐357. Question: 6
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Question: C. Intubate the patient
Khilnani GC, Banga A. Noninvasive ventilation in patients with chronic obstructive airway disease. Int J Chron Obstruct Pulmon Dis. 2008;3(3):351‐357. Question: 7
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Question: A. Hemodynamically stable cardiogenic pulmonary edema patients
Masip J, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta‐analysis. JAMA 2005; 294:3124
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1.Lindenauer PK, et al. Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of COPD. JAMA Intern Med. 2014; 174(12): 1982‐1993
2.Weng CL, Zhao YT, Liu QH, et al. Meta‐analysis: noninvasive ventilation in acute cardiogenic pulmonary edema. Ann Intern Med. 2010;152(9):590‐600
Question: Question: C. Continuous positive airway pressure
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Squadrone V, et al. Piedmont Intensive Care Units Network (PICUN). Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial. JAMA 2005;293(5):589‐595.
*Esteban A, et al. Noninvasive positive‐pressure ventilation for respiratory failure after extubation. N Engl J Med 2004; 350:2452.
*Diaz GG, et al. NPPV to treat hypercapnic coma secondary to respiratory failure. Chest. 2005; 127(3):952
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Question: Question: E. All of the above
Girou E, et al. Association of noninvasive ventilation
With nosocomial infections and survival in critically ill patients.
JAMA. 2000;284(18):2361.
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Question: A 66 yo man is evaluated for possible extubation. He was admitted for a severe COPD exacerbation 3 days ago. His carbon dioxide remained markedly elevated despite a trial of noninvasive ventilation, and he was therefore intubated and placed on invasive MV. He has improved with treatment of his COPD. His medications are methylprednisolone, albuterol, ipratropium, propofol, and levofloxacin.
He is awake & responsive. Afebrile, BP 138/82, HR 96, RR 20. Breath sounds are decreased bilaterally with no wheezing. A small amount of thin secretions is noted with endotracheal suctioning.
ABG has returned to his baseline: 7.36/ 55/ 70 (FIO2 of 0.35). He tolerates a weaning trial well & the decision is made to extubate.
Question: Which of the following interventions will decrease this patient's risk for reintubation?
Incentive spirometry every 2 hours
B. Inhaled helium‐oxygen mixture
C. Nebulized N‐acetylcysteine
D. Noninvasive positive pressure ventilation
Question: Which of the following interventions will decrease this patient's risk for reintubation?
Incentive spirometry every 2 hours
B. Inhaled helium‐oxygen mixture
C. Nebulized N‐acetylcysteine
D. Noninvasive positive pressure ventilation
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Noninvasive Positive Pressure Ventilation (NPPV) for Vent Weaning
• NPPV shortly after extubation for a 24‐hour period reduced the need for reintubation of intubated patients with COPD and compensated hypercapnia after a successful weaning trial
Ferrer M,, et al. Non‐invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomized controlled trial. Lancet. 2009;374(9695):1082‐1088
Noninvasive Positive Pressure Ventilation (NPPV) for Vent Weaning
• A weaning strategy that includes NPPV may reduce:
• Total duration of mechanical ventilation
• Need for reintubation
• Need for tracheostomy
• Ventilator‐associated pneumonia
• Length of stay in ICU and in Hospital
• Mortality
Burns KE, et ; Cochrane Database Syst Rev. 2013 Alternative Answers
• Incentive Spirometry reduces risk of postoperative pulmonary complication, but does not have a role in the routine management of nonsurgical patients following extubation
• The reduced gas density of helium‐oxygen mixtures (heliox) reduces resistance to airflow and decreases work of breathing in patients with obstructive lung disease, but there is insufficient evidence to support the routine use of heliox in the management of COPD exacerbations
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Alternative Answers
• N‐acetylcysteine is a mucolytic agent used to thin secretions in patients with excess mucus production
• Unlikely to benefit this patient because he had minimal secretions prior to extubation
• Nebulized N‐acetylcysteine may trigger bronchospasm
Key Point
• Application of NPPV prophylactically after extubation for a 24‐hour period reduced the need for reintubation in trials of intubated patients with COPD and compensated hypercapnia during a spontaneous breathing trial
• In contrast, NPPV appears ineffective, and potentially harmful, if not initiated until after the onset of post‐
extubation respiratory failure*
*Esteban A, et al. Noninvasive positive‐pressure ventilation for respiratory failure after extubation. N Engl J Med 2004; 350:2452.
Question: A 62yo woman w/ hx of CHF & an EF of 25% is admitted for a 2‐week history of progressive dyspnea. Her current medications are carvedilol, Lisinopril, spironolactone, and furosemide.
On exam, she is afebrile, BP 80/48, HR is 106, and RR is 30. O2 sat is 89% on a NRB mask. She is confused and periodically removes the mask. She has bilateral inspiratory crackles. There is a grade 2/6 holosystolic
murmur and an S3 gallop at the apex.
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Laboratory and Radiology
• Hgb
• WBC
• PLT
• BUN
• Creatinine
• Lactic acid
• ABG
12 g/dL
8200/µL
250,000/µL
52 mg/dL
2.8 mg/dL
4.2 mmol/L
7.48/ 30/ 58 (on 100%)
Question: Which of the following is the most appropriate next step in treatment?
A.
B.
C.
D.
E.
Endotracheal intubation and mechanical ventilation
Nitroglycerine infusion
Noninvasive positive pressure ventilation
Placement of a pulmonary artery catheter
Furosemide
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Question: Which of the following is the most appropriate next step in treatment?
A.
B.
C.
D.
E.
Endotracheal intubation and mechanical ventilation
Nitroglycerine infusion
Noninvasive positive pressure ventilation
Placement of a pulmonary artery catheter
Furosemide
Alternative Answers
• Nitroglycerine infusion and furosemide are useful in managing acute decompensated heart failure, but could worsen this patient’s hypotension and multi‐organ failure
• Pulmonary artery catheters can be useful in selected patients
• Their use does not improve survival of critically ill patients
• Placement should never take precedence over managing respiratory failure
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Question: Question: D. Intubation, placement of 2 large‐bore IVs, & fluid bolus
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Question: Question: B. Endotracheal intubation
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Lazarus SC. Clinical Practice. Emergency treatment of asthma. N Engl J Med 2010;368:755‐764.
Question: Question: C. Prolonged expiratory time
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Lazarus SC. Clinical Practice. Emergency treatment of asthma. N Engl J Med 2010;368:755‐764.
Question: Question: C. The plateau to peak pressure gradient
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Tobin MJ. Monitoring respiratory mechanics in spontaneously breathing
patients. In: Tobin MJ, editor. Principles and practice of intensive care
monitoring. New York: McGraw‐Hill; 1998. p. 617–653.
Question: 21
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Question: D. Disconnect patient from the ventilator
Lazarus SC. Clinical Practice. Emergency treatment of asthma. N Engl J Med 2010;368:755‐764.
Mughal MM, et al. Auto‐PEEP: Mechanisms and treatment Cleveland Clin
J Med 2005;72:801‐809
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Question: Question: B. Bedside vital capacity
Question: 23
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Question: E. Intubate the patient because muscles of respiration are fatiguing
H2O
20 ml/kg ‐30 mm Mehta S. Neuromuscular disease causing acute respiratory failure. Respir Care. 2006;51(9):1016‐1021
Question: 24
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Question: E. Intubate the patient and initiate mechanical ventilation
Wu JY. The role on non‐invasive ventilation and factors predicting
Outcome in myasthenic crisis. Neurocrit Care 2009:10(1):35‐42
Question: 25
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Question: 26
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Question: B. Acute respiratory distress syndrome (ARDS)
Timing
Within 1 week of a known clinical insult
Chest Imaging
Bilateral opacities – not fully explained by effusions, lobar/lung collapse, or nodules
Origin of edema
Respiratory failure not fully explained by cardiac failure or fluid overload; Need objective assessment (eg. Echocardiography) to exclude hydrostatic edema if no risk factor for ARDS is present
Oxygenation
Mild
200 mm Hg < PaO2/FiO2 ≤ 300 mm Hg with PEEP or CPAP ≥ 5 cm H2O
Moderate
100 mm Hg < PaO2/FiO2 ≤ 200 mm Hg with PEEP ≥ 5 cm H2O
Severe
PaO2/FiO2 ≤ 100 mm Hg with PEEP ≥ 5 cm H2O
ARDS Definition Task Force. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307:2526‐33
Severity
Ventilator Days in Survivors
Mortality
Mild
5
27%
Moderate
7
32%
Severe
9
45%
ARDS Definition Task Force. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307:2526‐33
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Tomashefski JF. Pulmonary pathology of the adult respiratory distress syndrome. Clin Chest Med 1990;11(4):593.
Tomashefski JF. Pulmonary pathology of the adult respiratory distress syndrome. Clin Chest Med 1990;11(4):593.
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Severe Hypoxemia
Impaired carbon dioxide elimination
Ware LB and Matthay MA. The Acute Respiratory Distress Syndrome. NEJM 2000;342:1334‐1349
Ware LB and Matthay MA. The Acute Respiratory Distress Syndrome. NEJM 2000;342:1334‐1349
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Question: Question: A. 300 mL
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ARDSNET investigators. Ventilation with lower tidal volumes as compared with traditional volumes for acute lung injury and the acute respiratory distress syndrome. NEJM 2000; 342:1301‐1308
Question: Question: E. Maintain the current ventilator settings
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ARDSNET investigators. Ventilation with lower tidal volumes as compared with traditional volumes for acute lung injury and the acute respiratory distress syndrome. NEJM 2000; 342:1301‐1308.
Question: Question: B. Decrease tidal volume
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ARDSNET investigators. Ventilation with lower tidal volumes as compared with traditional volumes for acute lung injury and the acute respiratory distress syndrome. NEJM 2000; 342:1301‐1308
Question: Question: B. Initiate scheduled doses of furosemide
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Wiedemann HP, et al. Comparison of two fluid‐management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564‐2575. Wiedemann HP, et al. Comparison of two fluid‐management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564‐2575. Question: 34
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Question: • Begin an infusion of cisatracurium
Papazian L, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010;363: 1017‐16
Alhazzani, et al. Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta‐analysis of randomized controlled trials. Critical Care 2013;17:843
Papazian L, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010;363: 1017‐16
Alhazzani, et al. Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta‐analysis of randomized controlled trials. Critical Care 2013;17:843
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1 Guerin C, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368(23):2159‐68.
2 Taylor RS, et al. Inhaled Nitric Oxide in ARDS Study Group. JAMA 2004;291(13):1603‐9.
3 Lamontagne R, et al. Corticosteroid therapy in acute respiratory distress syndrome. CMAJ 2013.185(3):216‐221.
Question: Question: A. Increase PEEP to 10 cm H2O
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Bower RG, et al. Higher versus lower positive end‐expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004:351:327‐36.
Question: Question: B.
Pt should be placed on pressure support of 5 cm H2o for 30 min
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Epstein SK. Weaning from ventilatory support. Curr Opin Crit Care 2009;15:36‐43.
Tobin MJ, Jubran A. Weaning from mechanical ventilation. In: Principles and Practice of Mechanical Ventilation, McGraw Hill, New York 2006. p. 1185.
Estaban A, et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue MV. AJRCCM 2001;164:225
Question: Question: D. IM administration of epinephrine
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• Prompt administration of epinephrine is life‐saving
Ben‐Shoshan M, Clarke AE. Anaphylaxis: past, present and future. Allergy 2011;66:1‐14.
Little F, Hollingsworth H. Anaphylaxis. In: Irwin RS, Rippe JM, eds. Intensive Care Medicine. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2008
Ben‐Shoshan M, Clarke AE. Anaphylaxis: past, present and future. Allergy 2011;66:1‐14.
Little F, Hollingsworth H. Anaphylaxis. In: Irwin RS, Rippe JM, eds. Intensive Care Medicine. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2008
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Kumar A, Parrillo JE. Shock:classification, pathophysiology,
And approach to management. In: Parrillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management
In the Adult. 3rd ed. Philadelphia: Mosby: 2008:377‐422.
Kumar A, Parrillo JE. Shock:classification, pathophysiology,
And approach to management. In: Parrillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management
In the Adult. 3rd ed. Philadelphia: Mosby: 2008:377‐422.
Kumar A, Parrillo JE. Shock:classification, pathophysiology,
And approach to management. In: Parrillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management
In the Adult. 3rd ed. Philadelphia: Mosby: 2008:377‐422.
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Kumar A, Parrillo JE. Shock:classification, pathophysiology,
And approach to management. In: Parrillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management
In the Adult. 3rd ed. Philadelphia: Mosby: 2008:377‐422.
Question: 41
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Question: A. A decrease in SBP(>10 mmHg) on inspiration
Spodick DH. Acute cardiac tamponade. N Engl J Med 2003;349:684.
Kumar A, Parrillo JE. Shock:classification, pathophysiology,
And approach to management. In: Parrillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management
In the Adult. 3rd ed. Philadelphia: Mosby: 2008:377‐422.
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Kumar A, Parrillo JE. Shock:classification, pathophysiology,
And approach to management. In: Parrillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management
In the Adult. 3rd ed. Philadelphia: Mosby: 2008:377‐422.
Kumar A, Parrillo JE. Shock:classification, pathophysiology,
And approach to management. In: Parrillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management
In the Adult. 3rd ed. Philadelphia: Mosby: 2008:377‐422.
Kumar A, Parrillo JE. Shock:classification, pathophysiology,
And approach to management. In: Parrillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management
In the Adult. 3rd ed. Philadelphia: Mosby: 2008:377‐422.
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Kumar A, Parrillo JE. Shock:classification, pathophysiology,
And approach to management. In: Parrillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management
In the Adult. 3rd ed. Philadelphia: Mosby: 2008:377‐422.
Kumar A, Parrillo JE. Shock:classification, pathophysiology,
And approach to management. In: Parrillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management
In the Adult. 3rd ed. Philadelphia: Mosby: 2008:377‐422.
Physiologic Variable
Preload
Pump function
Afterload
Clinical
measurement
PCWP
CO
SVR
Hypovolemic
↓
↓
↑
Cardiogenic
↑
↓
↑
Extracardiac Obstructive
↓ or ↑
↓
↑
Distributive
↓ or ↔
↑
↓
Kumar A, Parrillo JE. Shock:classification, pathophysiology,
And approach to management. In: Parrillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management
In the Adult. 3rd ed. Philadelphia: Mosby: 2008:377‐422.
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Question: Question: A. Norepinephrine’s actions at both alpha and beta receptors reliably improve cardiac output
Lollgen H, Drexler H. Use of inotropes in the critical care
Setting. Crit Care Med 1990;18:S56.
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Drug
Alpha‐1
Beta‐1
Beta‐2
Dopaminergic
Predominant clinical effects
Phenylephrine
+++
O
O
O
SVR ↑↑, CO↔/↑
Norepinephrine
+++
++
O
O
SVR↑↑,CO↑
Epinephrine
+++
+++
++
O
CO ↑↑, SVR ↓(low dose)
SVR↔/↑ (high dose)
Dopamine
0.5 to 2.0
O
+
O
++
SVR↓, CO↔/↑
Dopamine
5 to 10
+
++
O
++
CO↑,SVR↔/↑
Dopamine
10 to 20
++
++
O
++
SVR↑↑, CO↑
Dobutamine
O/+
+++
++
O
CO↑, SVR↓
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Polito A, et al. Vasopressin for treatment of vasodilatory shock:
An ESICM systematic review and meta‐analyisis. Int Care Me 2012;38(1):9.
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Lollgen H, Drexler H. Use of inotropes in the critical care
Setting. Crit Care Med 1990;18:S56.
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Question: A 74 yo woman presented to ED for a UTI and hypotension. ABX were administered, and she was admitted. 6 hours after admission, she is confused & lethargic.
Temp is 37.8 °C (100.0 °F), BP 88/40, HR, RR 28. Extremities are cool & mottled. She’s had no urine output since admission.
Hgb 9.5, WBC 16,700, creatinine & electrolytes WNL.
Which of the following is the most appropriate next step in management?
Question: A 74 yo woman presented to ED for a UTI and hypotension. ABX were administered, and she was admitted. 6 hours after admission, she is confused & lethargic.
Temp is 37.8 °C (100.0 °F), BP 88/40, HR, RR 28. Extremities are cool & mottled. She’s had no urine output since admission.
Hgb 9.5, WBC 16,700, creatinine & electrolytes WNL.
Which of the following is the most appropriate next step in management?
B. Intravenous fluid bolus
Sepsis – Key Point
•Patients with severe sepsis should receive immediate volume resuscitation
Dellinger RP, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580
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Alternative Answers‐ Pressors for Sepsis
• Vasopressors should not be initiated for sepsis until adequate fluid resuscitation has been given
• Norepinephrine is 1st line
• Epinephrine is now 2nd line
• Vasopressin may be added, but only at a dose of no more than 0.04 units/min, and never alone
• Dopamine can be used in selected patients with relative bradycardia and at low risk of tachyarrhythmias
• Phenylephrine is occasionally used in patients w/ persistent tachycardia
Russell JA, et al. Vasopressin versus Norepineprine infusion in paients with
Septic shock. N Engl J Med 2008. 358:877‐887
Alternative Answers – Steroids for Sepsis
• IV hydrocortisone at a dose of 200 mg per day should be used only if adequate fluid resuscitation and vasopressor therapy are unable to maintain hemodynamic stability
• ACTH stimulation test is no longer recommended
• Steroids should be tapered when vasopressors are no longer required
Sprung CL, et al. Hydrocortisone therapy
For patients with septic shock. N Engl J Med 2008.
358:111‐124
Alternative Answers – Blood Transfusions for Sepsis
• In the absence of persistent tissue hypoperfusion, acute hemorrhage, or myocardial ischemia, PRBCs should be transfused only if hgb < 7.0 g/dL
to target a hgb concentration of 7‐9 g/dL
Hebert PC, et al. A multicenter, randomized,
Controlled clinical trial of transfusion in Critical care. N Engl J Med 1999. 340:409‐417.
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Sepsis & Septic Shock
• Sepsis is a systemic, deleterious host response to infection
• Severe Sepsis = acute organ dysfunction 2nd to documented or suspected infection
• Septic Shock includes hypotension not reversed with fluid resuscitation
Dellinger RP, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580
Dellinger RP, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36(1):296‐327.
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2012 Diagnostic Criteria for Sepsis
=Infection (documented or suspected), PLUS “some” of the following:
• Fever
• Hypothermia
• Tachycardia
• Tachypnea
• AMS
• Hypotension
• Mottling
• Hypoxemia
• Oliguria
• Ileus
• Leukocytosis
• Leukopenia
• Bandemia
• AKI
• Coagulopathy
• Thrombocytopenia
• Hyperbilirubinemia
• Hyperlactatemia
Dellinger RP, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580
Severe Sepsis – sepsis‐induced tissue hypoperfusion or organ dysfunction with any of the following, thought to be due to the infection:
• Hypotension
• Elevated lactate level
• Oliguria <0.5 mL/kg/hr for > 2 hours
• Acute lung injury
• Creatinine > 2.0
• Bilirubin > 2
• PLT count < 100,000
• INR > 1.5
Dellinger RP, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580
Question: 52
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Question: B. Diagnostic paracentesis
Dellinger RP, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580
Surviving Sepsis Campaign Care Bundles
TO BE COMPLETED WITHIN 3 HOURS
1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer a minimum of 30 mL/kg crystalloid for hypotension or lactate >4 mmol/L
Dellinger RP, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580
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Surviving Sepsis Campaign Care Bundles
TO BE COMPLETED WITHIN 6 HOURS
1. Apply vasopressors (after fluid resuscitation) to maintain a MAP >65 mm Hg
2. For septic shock:
•
•
Measure CVP and target >8 mm Hg
Measure central venous oxygen saturation (ScvO2) and target >70%
3. Repeat lactate if initial was elevated, and target normalization
Dellinger RP, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580
Question: Question: C. Norepinephrine
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Dellinger RP, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med Question: Question: E.
Lorazepam
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Amato L, Minozzi S, Davoli M. Efficacy and safety of pharmacological interventions for the treatment of the Alcohol Withdrawal Syndrome. Cochrane Database Syst Rev. 2011
Amato L, Minozzi S, Davoli M. Efficacy and safety of pharmacological interventions for the treatment of the Alcohol Withdrawal Syndrome. Cochrane Database Syst Rev. 2011
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Question: Question: D. GI decontamination with activated charcoal is superior to gastric lavage
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Bronstein AC, et al. 2011 Annual report of the American Association of Poison
Control Centers’ National Poison Data System (NPDS): 29th Annual Report. Clin Toxicol 2012;50(10):911‐1164.
Question: Question: D. Sodium bicarbonate infusion
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Body R, et al. Guidelines in Emergency Medicine Network (GEMNet): guideline for the management of tricyclic antidepressant overdose. Emerg Med J 2011:28(4):347‐368.
Body R, et al. Guidelines in Emergency Medicine Network (GEMNet): guideline for the management of tricyclic antidepressant overdose. Emerg Med J 2011:28(4):347‐368.
Body R, et al. Guidelines in Emergency Medicine Network (GEMNet): guideline for the management of tricyclic antidepressant overdose. Emerg Med J 2011:28(4):347‐368.
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Question: C. Hemodialysis
Question: C. Hemodialysis
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Boyer, EW. Aspirin poisoning in adults. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2014.
Boyer, EW. Aspirin poisoning in adults. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2014.
Question: 61
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Question: B. Hyperbaric oxygen therapy
Garrabou G, et al. Hyperbaric oxygen therapy for carbon
Monoxide poisoning. Intensive Care Med. 2011;37(10):1711‐1712
Garrabou G, et al. Hyperbaric oxygen therapy for carbon
Monoxide poisoning. Intensive Care Med. 2011;37(10):1711‐1712
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Garrabou G, et al. Hyperbaric oxygen therapy for carbon
Monoxide poisoning. Intensive Care Med. 2011;37(10):1711‐1712
Question: 63
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Question: C. The presence of carboxyhemoglobin
Garrabou G, et al. Hyperbaric oxygen therapy for carbon
Monoxide poisoning. Intensive Care Med. 2011;37(10):1711‐1712
Question: 64
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Question: B. IV diltiazem and lorazepam
McCord J, et al; American Heart Association Acute Cardiac Care Committee of the Council
On Clinical Cardiology. Management of cocaine‐associated chest pain and myocardial Infarction: a scientific statement from the American Heart Association Acute Cardiac Care
Committee of the Council on Clinical Cardiology. Circulation 2008;117(14):1897‐1907.
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Question: Question: A. Ethylene glycol toxicity
Question:
D. Intravenous fomepizole and hemodialysis
E. Supportive Care
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Question:
D. Intravenous fomepizole and hemodialysis
E. Supportive Care
Jammalamadaka E, Raissi S. Ethylene glycol, methanol and isopropyl
Alcohol intoxication. Ma J Med Sci 2010;339(3):276‐281.
Jammalamadaka E, Raissi S. Ethylene glycol, methanol and isopropyl
Alcohol intoxication. Ma J Med Sci 2010;339(3):276‐281.
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Jammalamadaka E, Raissi S. Ethylene glycol, methanol and isopropyl
Alcohol intoxication. Ma J Med Sci 2010;339(3):276‐281.
Jammalamadaka E, Raissi S. Ethylene glycol, methanol and isopropyl
Alcohol intoxication. Ma J Med Sci 2010;339(3):276‐281.
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Question: Question: A. Cholinergic crisis
Tafuri J, Roberts J. Organophosphate poisoning. Ann Emerg
Med 1987;16:193
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Question: Question: B. Atropine
Eddleston M, et al. Management of severe organophosphorous
Pesticide poisoning. Crit Care 2002;6:259.
70
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Question: Question: E.
The nitroprusside infusion
Mokhlesi B, Corbridge T. Toxicology in the critically ill patient.
Clin Chest Med 2003;24:689.
71
4/20/2015
Mokhlesi B, Corbridge T. Toxicology in the critically ill patient.
Clin Chest Med 2003;24:689.
Question: Question: D. Monitoring without intervention
72
4/20/2015
De Gasperi A, et al. Acute liver failure: managing coagulopathy and the Bleeding diathesis. Transplant Proc 2009;41:1256‐59.
Question: Question: B. Hydrochlorothiazide
73
4/20/2015
Berl T, Taylor J. Disorders of water balance. In: Fink MP, Abraham E,
Vencent JL, it al., eds. Textbook of Critical Care. Philadelphia: Elsevier Saunders; 2005:1085‐1096
Question: Question: C. Hypotonic hypovolemic hyponatremia
74
4/20/2015
Adrogue HJ, Madias NE. Hyponatremia. N Engl J Med
2000;342:1581‐1589.
Question: Question: D. MRI of the brain
75
4/20/2015
Sterns RH, et al. Osmotic demyelination syndrome following correction
Of hyponatremia. N Engl J Med 1986;314:1535.
Brunner JE, et al. Central pontine myelinolysis and pontine lesions
After rapid correction of hyponatremia: a prospective magnetic resonance imaging study. Ann Neurol 1990;27:61.
Adrogue HJ, Madias NE. Hyponatremia. N Engl J Med
2000;342:1581‐1589.
Brunner JE, et al. Central pontine myelinolysis and pontine lesions
After rapid correction of hyponatremia: a prospective magnetic resonance imaging study. Ann Neurol 1990;27:61.
Question: 76
4/20/2015
Question: C. Intravenous unfractionated heparin
Carlbom DJ, Davidson BL. Pulmonary embolism in the critically ill. Chest 2007;132:313‐324.
Kearon C, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th
ed: American College of Chest Physicians Evidence0Based Clinical Practice Guidelines. Chest 2012;141:e419S.
77
4/20/2015
Question: Question: C. 185/110
Mrik PE, Rivera R. Hypertensive emergencies: an update. Curr
Opin Crit Care 2011;17(6):569‐580.
78
4/20/2015
Mrik PE, Rivera R. Hypertensive emergencies: an update. Curr
Opin Crit Care 2011;17(6):569‐580.
Question: Question: B. Delirium
79
4/20/2015
Schiemann A, et al. Managing ICU delerium. Curr Opin Crit Care 2011;17(2):131‐140.
Question: Question: D. Lorazepam
80
4/20/2015
Strawn JR, Keck PE, Caroff SN. Neuroleptic malignant syndrome. Am J Psychiatry 2007;164(6):870‐876.
Strawn JR, Keck PE, Caroff SN. Neuroleptic malignant syndrome. Am J Psychiatry 2007;164(6):870‐876.
Question: 81
4/20/2015
Question: A. Endotracheal intubation
Malde B, Regalado J, Greenberger PA. Investigation of angioedema associated with the use of angiotensin‐converting enzyme inhibtors and angiotensin receptor blockers. Ann Allergy Asthma Immunol 2007;98(1):57‐63.
Malde B, Regalado J, Greenberger PA. Investigation of angioedema associated with the use of angiotensin‐converting enzyme inhibtors and angiotensin receptor blockers. Ann Allergy Asthma Immunol 2007;98(1):57‐63.
82
4/20/2015
Grant NN, et al. Clinical experience with angiotensin‐converting enzyme inhibitor‐induced angioedema. Otolaryngol Head Neck Surg
2007;137:931.
Bas M, et al. A randomized trial of icatibant in ACE‐
inhibitor‐induced angioedema. N Engl J Med 2015;372:418
Question: Question: B. Intramuscular epinephrine and inhaled albuterol
83
4/20/2015
Sheikh A, et al. Adrenaline for the treatment of anaphylaxis: cochrane
systematic review. Allergy. 2009;64(2):204‐212
Sheikh A, et al. Adrenaline for the treatment of anaphylaxis: cochrane
systematic review. Allergy. 2009;64(2):204‐212
Sheikh A, et al. Adrenaline for the treatment of anaphylaxis: cochrane
systematic review. Allergy. 2009;64(2):204‐212
84
4/20/2015
Question: Question: B. IV clindamycin and IV vancomycin
85
4/20/2015
Chu VH. Staphylococcal toxic shock syndrome. In: UpToDate, Basow, Waltham, MA 2014.
Chu VH. Staphylococcal toxic shock syndrome. In: UpToDate, Basow, Waltham, MA 2014.
Chu VH. Staphylococcal toxic shock syndrome. In: UpToDate, Basow, Waltham, MA 2014.
86
4/20/2015
Question: Question: D. Seizure
87
4/20/2015
Adenoscan (adenosine) [prescribing information]. Deerfield, IL: Astellas; August 2014.
Question: Question: D. Peripheral blood smear
88
4/20/2015
Question: Question: A. Start plasma exchange
George JN. Clinical practice. Thrombotic
Thrombocytopenic purpura. N Engl J Med
2006;354:1927
89
4/20/2015
George JN. Clinical practice. Thrombotic
Thrombocytopenic purpura. N Engl J Med
2006;354:1927
George JN. Clinical practice. Thrombotic
Thrombocytopenic purpura. N Engl J Med
2006;354:1927
90
4/20/2015
Question: Question: A. Lorazepam, 0.1 mg/kg
Brophy GM, et al. Guidelines for the evaluation and management
Of status epilepticus. Neurocrit Care 2012;17:3‐23.
91