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Principles of Surgery (POS) Critical Care Review

Principles of Surgery (POS) Critical Care Review. D.Kubelik University of Ottawa POS Lecture Series 2012 Adapted from D.Kim. Objectives. review ATLS principles discuss basic physiologic concepts as applicable to critical care/ICU

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Principles of Surgery (POS) Critical Care Review

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  1. Principles of Surgery (POS)Critical Care Review D.Kubelik University of Ottawa POS Lecture Series 2012 Adapted from D.Kim

  2. Objectives • review ATLS principles • discuss basic physiologic concepts as applicable to critical care/ICU • apply these principles to case based scenarios

  3. Critical Care

  4. Cardiac Physiology

  5. PAWP ~ Left atrial pressure • CVP ~ Right atrial pressure

  6. Exams • Approaches to questions that give central pressure data • Is the heart working well? • Use the cardiac index/cardiac output • If the CO is high look for distributive causes of shock • If CO is low where is the problem • Look at where pressures are increasing • This is usually proximal to the disease • E.g. PE  high RV and CVP but normal wedge

  7. Shock • Approach to a hypotensive patient • MAP = CO x SVR Decreased SVR • Sepsis • Neurogenic Shock • Adrenal Insufficiency • Liver Failure • Anaphylaxis • Medications Decreased Cardiac Output

  8. Classifying Shock • Hypovolemic • Cardiogenic • Obstructive • Distributive • (Endocrine) • Can have cardiogenic or distributive components

  9. A 51 YO patient with known lung cancer undergoing radiation therapy presents to the hospital with worsening shortness of breath. He becomes hypotensive and gets admitted to the ICU. He has a CI of 1.9, CVP 20, PAWP 20, RV pressures 35/20 PA pressures 32/20. What is the most likely diagnosis • PE • MI • Pneumonia and sepsis • Cardiac Tamponade

  10. Tamponade • Intrapericardial pressure equalizes and opposes atrial and ventricular pressures • Hypotension, tachycardia, high CVP and pulsus paradoxus (drop >10mmHg in pressure with inspiration)

  11. A 51 YO patient with known lung cancer undergoing radiation therapy presents to the hospital with worsening shortness of breath. He becomes hypotensive and gets admitted to the ICU. He has a CI of 1.9, CVP 18, PAWP 10, RV pressures 50/33 PA pressures 50/20. What is the most likely diagnosis • PE • MI • Pneumonia and sepsis • Cardiac Tamponade

  12. Treatments

  13. 1. Which of the following is/are not a determinant of CO? a) end-diastolic pressure b) afterload c) contractility d) heart rate e) ventricular interaction

  14. Key Equations CO = HR x SV SV = EDV – ESV EF = SV / EDV MAP = CO x SVR

  15. Frank-Starling

  16. 2. Which of the following mechanisms are the body’s most important defenses in severe oxygen transport deficiency? a) hyperventilation b) reduction of VO2 c) organ redistribution of CO d) shifting of the O2 dissociation curve e) widening of the a-v O2 content

  17. The oxyhemoglobin dissociation curve relates the partial pressure of O2 in the blood (PO2) to the % saturation of hemoglobin with oxygen (SO2). For a given SO2, the PO2 depends on all of the following, EXCEPT? 1) temperature 2) serum potassium 3) pH 4) RBC content of 2,3-DPG

  18. Hemoglobin-O2 Dissocation Curve

  19. Remembering the dissociation curve • A shift to the right means oxygen is unloaded “Exercising muscle needs oxygen” • Increased temp, CO2, acidosis, glycolysis • 2,3 DPG is a glycolysis breakdown product • Compare curves for a set pO2

  20. 3. What is the definition of the shock state? a) low BP to maintain normal metabolic and nutritional metabolism b) low CO to maintain normal metabolic and nutritional metabolism c) inadequate tissue perfusion to maintain normal metabolic and nutritional metabolism d) abnormal vascular resistance to maintain normal metabolic and nutritional metabolism

  21. DO2-VO2 Equations

  22. 4. In which of the following is CVP a reliable guide in fluid management? a) CXR with pulmonary edema b) RVEDP = CVP c) MV disease d) LVEF = 0.4 e) PHTN

  23. CVP and PCWP

  24. 5. Which of the following are determinant of mixed venous O2 saturation (SvO2)? a) VO2 b) CO c) Hb Concentration d) arterial O2 saturation e) myocardial VO2

  25. 6. Which of the following is/are associated with en elevated SvO2? a) septic shock b) distal migration of the PAC c) lactic acidosis d) left-to-right shunt e) right-to-left shunt

  26. 7. Regarding CO2 kinetics, which of the following is/are true? a) total amount of CO2 produced is equivalent to the total amount of O2 consumed b) the a-v difference of CO2 is the same as O2 c) end-tidal CO2 is the same as paCO2 d) all of the above

  27. CO2 metabolism

  28. 8. Which of the following is/are associated with increased dead space ventilation? a) low CO b) ARDS c) PE d) PHTN e) all of the above

  29. 9. With regards to ventilatory mechanics, which of the following statements is/are true? a) WOB consume 2% of total body O2 consumption b) WOB may increase to 50% in the postop patient c) the increased WOB in COPD is due primarily to an increased inspiratory effort d) airway pressure reflects the compliance of the chest wall and diaphragm as well as the lungs e) C = V / P

  30. Compliance & Resistance

  31. 10. Which of the following indicates the need for immediate ventilatory support? a) RR > 35bpm b) paCO2 >60mmHg c) A-a O2 gradient > 350mmHg d) VD/VT >0.6 e) shunt fraction greater than 5%

  32. 11. ARDS is characterized by: a) bilateral pulmonary infiltrates b) paO2/FiO2 <300mmHg c) PCWP >18mmHg d) hypoxemia with hypercarbia e) increased dead space ventilation and increased lung compliance

  33. 12. Which of the following treatment are appropriate for the ARDS patient? a) MV b) albumin and Lasix c) PEEP d) ECMO e) routine steroids

  34. 13. With regards to FRC, which of the following is/are true? a) FRC = RV + TV b) atelectasis occurs when the FRC falls below the closing volume (CV) c) FRC = ERV + RV d) FRC is increased by PEEP

  35. PFTs

  36. 14. Which of the following may be seen with shock? a) hyperglycemia b) negative nitrogen balance c) lactic acidosis d) metabolic alkalosis e) hyperkalemia

  37. 15. 24yo female undergoes ex lap for a Class IV hemorrhage and is transfused >12U PRBCs. Which of the following is most appropriate? a) CaCl b) FFP c) plt d) correction of hypothermia e) heparin

  38. Trauma

  39. Primary Survey • 22yo male post-MVC, combative, pale, bleeding profusely from nose and mouth • R thigh deformity and scalp laceration • BP=80/40; HR=130; RR=40 Which of the initial management options is correct?

  40. a) esophageal intubation, rapid infusion RL 2L via CVC, traction, suture scalp b) ETT, rapid infusion RL 2L via 2 peripheral IVs, traction, suture scalp, exposure c) O2 by mask, rapid infusion RL 2L via 2 peripheral IVs, traction, pressure scalp, exposure d) cricothyroidotomy, rapid infusion RL 2L via 2 peripheral IVs, traction, pressure scalp, exposure e) jaw thrust, rapid infusion RL 2L via 2 peripheral IVs, traction, suture scalp, exposure

  41. 32yo female jumper from 10th floor • head and extremity injuries • apneic in ED By which method is a definitive airway provided for this patient?

  42. a) orotracheal intubation b) nasotracheal intubation c) cricothyroidotomy d) needle cricothyroidotomy \

  43. 22 yo male automobile fire • carbonaceous sputum, stridor • failed nasotracheal intubation • O2=97% Prior to orotracheal intubation, what step(s) is/are correct?

  44. a) preoxygenation via high-flow O2 b) cricoid pressure c) prepare for crico d) axial stabilization e) all of the above

  45. 56yo male ped struck • multiple facial lacs, profuse bleeding from nose and deformed mandible • periorbital swelling and inability for upward gaze • RR=40, stridor, anxious What is the appropriate next sequence?

  46. a) O2, CT, suture, lateral c-spine b) nasotracheal intubation, posterior packing, lateral c-spine, CT face c) endotracheal intubation, posterior packing, lateral c-spine, CT scan of face d) endotracheal intubation, posterior packing, lateral c-spine, x-ray face e) posterior packing, endotracheal intubation, lateral c-spine, CT scan of face

  47. 22 yo male stab along ant. border of SCM 1 cm sup. to cricoid • platysma penetrated • VSS Which of the following management option(s) is are correct?

  48. a) admit to ICU and observe for airway obstruction and expanding hematoma b) perform carotid angio(graphy), if normal, observe c) perform carotid angio, barium swallow, rigid esophagoscopy, if normal, observe d) explore neck e) perfrom carotid angio, barium swallow, flexible esophagoscopy, if normal, observe

  49. 24 yo male unrestrained driver MVC • hypoxic despite O2 • CXR - bilateral chest infiltrates Which of the following in the most likely diagnosis?

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