Critical Care Conflict of Interest/Disclosures ABIM Certification Exam n None Review Course Leslie Zimmerman, MD Professor of Clinical Medicine, UCSF ICU Director, SFVAMC Question 1 Lecture Outline A 42 yo woman is brought to the ED pulseless. Resuscitation is started. Extremities reveal multiple n Resuscitation (first 6 hours) skin scars c/w with long standing IVDU. Peripheral IV access cannot be obtained. Which of the n Ventilators/ARDS (first 6 hours) following is the best option for access? n Sepsis A. Continued attempt at peripheral vein access n GI issues B. Internal jugular vein n Odd and ends for $200 C. External jugular vein D. Femoral vein E. Intraosseus access 1
Question 1 Code blue access A 42 yo woman is brought to the ED pulseless. Neck access interferes with intubation and crowds Resuscitation is started. Extremities reveal multiple the head of the bed skin scars c/w with long standing IVDU. Peripheral IV access cannot be obtained. Which of the Femoral access: “accuracy” is difficult à no pulse following is the best option for access? so easy to confuse artery and vein (ABG in code may not distinguish) A. Continued attempt at peripheral vein access B. Internal jugular vein Intraosseus: quick access; can use x 24 hours C. External jugular vein • Do need to create a “space” in medullary bone D. Femoral vein • Infusions require pressure bag E. Intraosseus access Question 2 Intraosseous Access A 52 yo man admitted for pancreatitis suddenly becomes unresponsive and has no pulse or Create respirations. Resuscitation is started. Initial rhythm “pocket” with is PEA. Which of the following suggests a “Return IVP saline of Spontaneous Circulation” or ROSC during the code? All drips with A. A change to “fine” ventricular fibrillation on pressure bag monitor B. A sudden decrease in serum lactic acid C. A sudden increase in ET CO2 D. Pupils 4-5 mm in diameter 2
Question 2 Hospital Codes are changing…. A 52 yo man admitted for pancreatitis suddenly becomes unresponsive and has no pulse or § Hospital: More PEA and less respirations. Resuscitation is started. Initial rhythm Vtach/Vfib (better cardiac is PEA. Which of the following suggests a “Return interventions à smaller MIs, of Spontaneous Circulation” or ROSC during the more AICDs?) code? § Survival rates are better! (15.4%) A. A change to “fine” ventricular fibrillation on Lancet 2012;380:1473. § Separate study à if > 65 and monitor survived to d/c post code, B. A sudden decrease in serum lactic acid 50% alive at 1 year* C. A sudden increase in ET CO2 D. Pupils 4-5 mm in diameter * NEJM 2013;368:11. Question 2 ACLS– Using ET CO2 Monitoring Good à ETT A 52 yo man admitted for pancreatitis suddenly in airways becomes unresponsive and has no pulse or respirations. Resuscitation is started. Initial rhythm is PEA. Which of the following suggests a “Return of Spontaneous Circulation” or ROSC during the More circulation, more CO2 code? delivered to lungs, more Asystole usually next L www.nonin.c om exhaled; first sign of ROSC In contrast How about? A. A change to “fine” ventricular fibrillation on monitor Not good Improved B. A sudden decrease in serum lactic acid washout or drop in CO? C. A sudden increase in ET CO2 Falling ET CO2, less ET CO2 flat lines? D. Pupils 4-5 mm in diameter circulation, = tiring CPR Bad Apnea or ETT out performer à switch out 3
Question 3 Updates on BLS ACLS (2015)… A 52 yo man admitted with chest pain and has a n Chest compressions first SAME Vfib arrest. After 30 minutes, he is resuscitated. n 2 inches depth on adults, full recoil VSs post code are HR 110, BP 95/60, RR: n Check for breathing and carotid pulse at the intubated; no spontaneous breaths. He remains same time (10 seconds max) unresponsive. Cardiology is coming to the n Chest compressions 100/min à 100 -120/ min bedside. Next steps are: n Vasopressin: no advantage A. Anticoagulation n For suspected Opioid overdose : B. Central line access to target CVP 8-12 mmHg - pulse but diminished breathing: IM or IN C. Hypothermia to 32-34 o C (intra- D. Placement of an IABP nasal) Narcan E. Tight glucose control - if opiate-suspected cardiac arrest: Narcan autoinjector (IM) Question 3 Post Code Care A 52 yo man admitted with chest pain and has a § Determine cause: Vfib arrest. After 30 minutes, he is resuscitated. • Cardiac, PE, PTX, AAA rupture, GI bleed, VSs post code are HR 110, BP 95/60, RR: Drug, electrolytes, sepsis intubated; no spontaneous breaths. He remains § Maintain MAP > 65 unresponsive. Cardiology is coming to the bedside. Next steps are: § Don’t over or under -ventilate § Avoid hypoxemia, but don’t keep PaO2 > A. Anticoagulation 300 B. Central line access to target CVP 8-12 mmHg C. Hypothermia to 32-34 o C § Therapeutic hypothermia if remains D. Placement of an IABP unresponsive post code E. Tight glucose control 4
Therapeutic Hypothermia Therapeutic Hypothermia NEJM n Extended to in-hospital arrests 2002;346:557- 63. Target = n Extended to PEA arrests 33 o C. Best temperature? NEJM 2013; 369:2197-2206 NEJM 2002; 33 vs. 36 o C? No difference 346:549-56. Target 32- 34 o C. Definitely treat fever! Question 4 Question 3 A 52 yo man admitted with chest pain and has a The new qSOFA score helps to diagnose Vfib arrest. After 30 minutes, he is resuscitated. VSs post code are HR 110, BP 95/60, RR: early sepsis: intubated; no spontaneous breaths. He remains A. True unresponsive despite BP & HR. Cardiology is B. False coming to the bedside. Next steps are: Specifically post cardiac C. Hypothermia to 32-34 o C arrest? - “Tight” control (70 to 108 E. Tight glucose control mg/dL) no better than “good” control (up to 144 mg/dL) Intensive Care Med. 2007;33:2093 5
Question 4 Identifying Risk in Early Sepsis: ( intended to be used outside the ICU to ID The new qSOFA score helps to diagnose patient’s at risk of dying from sepsis) early sepsis: A. True B. False Sequential (Sepsis-related) quickSOFA (qSOFA): 2016 Organ Failure Assessment 1 point each: Even the old SOFA score was more of an “organ • respiratory rate ≥ 22/minute score (SOFA) • altered mentation Points for bad P/F ratio, MAP dysfunction” score, not a way to diagnose sepsis • systolic BP ≤ 100 mmHg or pressor needs, bilirubin, platelet count, creatinine/urine A score ≥ 2 is associated with output, GCS poor outcomes due to sepsis Sepsis Definition Epidemiology of Sepsis Sepsis is a clinical syndrome that has physiologic, biologic, and biochemical abnormalities caused by a dysregulated inflammatory response to infection. n Key elements are • Organ dysfunction …But better outcomes • Infection Septic shock is sepsis that has circulatory or metabolic abnormalities such as persistent hypotension or elevated lactate despite adequate More sepsis… fluid resuscitation SIRS: T > 38°C or < 36°C; HR >90; RR>24 or PaCO2 <32; WBC >12k or < 4k. > 2 = SIRS 6
Question 5 Question 5 A 75 year old man with… 75 year old man with pneumonia. T 104 o F , After 2L .9NS : pulse 110, BP 75/50 (MAP=58) pulse 115, BP 70/40. Exam: lethargic man with Hgb 10.5 crackles in the right base. At this time, you should: Labs: Hgb 10.5 mg/dl, WBC 18K with left shift, BUN of 54, lactic acid level 6 meq/L (nl .6-1.8) A. Assess volume status by some means B. Measure S MV O2 After cultures and broad spectrum antibiotics, C. Start ECMO 2L NS (20 cc/kg): pulse 110, BP 75/50 D. Start Norepinephrine IV to target MAP of 80 E. Transfuse packed RBCs Question 5 Trip down memory lane…Surviving Sepsis: Recommendations A 75 year old man with… Crit Care Med 2012 After 2L .9NS : pulse 110, BP 75/50 (MAP=58) Rivers E et al. Early goal-directed therapy in the treatment Hgb 10.5 of severe sepsis and septic shock. NEJM 2001;345:1368. Single RTC; single center At this time, you should: n CVP 8-12 mmHg A. Assess volume status by some means n MAP > 65 mmHg B. Measure S MV O2 n UO > .5 cc/kg/hr C. Start ECMO n SVC O2 sat (Scvo 2 ) > 70% or S MV o 2 > D. Start Norepinephrine IV to target MAP of 80 E. Transfuse packed RBCs 65% > Transfusion or Dobutamine for this last goal… Adherence low in f/u international performance study 7
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