ICCM - Quiz 2

Ventilation

Pulmonary perfusion

in healthy patients, ___________ is most effective in the lung apices and _______________________ is most effective in the lung bases

Ventilating a non-perfused portion of the lung causing physiologic dead space (i.e. pulmonary embolism)

Perfusing an area of the lung that is damaged (i.e. pneumonia, ARDS, COPD, Pulmonary Edema)

what are the two types of VQ mismatch?

by preferentially shunting blood to well-ventilated lung tissue by vasoconstricting blood flow to diseased lung tissue

how does the body attempt to improve VQ mismatch in pathology involving perfusion of damaged lung?

ARDS

Severe inflammatory process causing diffuse alveolar epithelial and capillary damage and NONCARDIOGENIC pulmonary edema

The Berlin Criteria

how do you diagnose ARDS?

Exudative (early)

Proliferative

Fibrotic (late)

what are the three phases of ARDS?

Bilateral opacities on CXR or CT not fully explained by effusion, lung collapse, or nodules

PF ratio 300 mmHg or less with 5 cm H2O or more PEEP

Respiratory failure not fully explained by cardiogenic pulmonary edema or volume overload

About 7 or less days from predisposing clinical insult, or new/worsening symptoms within prior week

Severity classification

what is the Berlin definition of ARDS?

Mild ARDS

PF ratio 201-300

Moderate ARDS

PF ratio 101-200

Severe ARDS

PF ratio < 100

PF ratio

The amount of oxygen in the blood in relation to the amount of supplemental oxygen you are providing to the patient

300

PF ratio less than _____ indicates acute respiratory failure

pneumonia

sepsis

inhalation injury

pulmonary contusion

near-drowning

fat embolus

burns

severe trauma

drug or alcohol overdose

pancreatitis

what are causes of ARDS?

ARDS

what does this XR show?

ARDS

what does this CT show?

Supportive treatment = Treat underlying cause

LOW TIDAL VOLUME VENTILATION is the only treatment shown to improve mortality in ARDS

High PEEP, Low Tidal Volume mechanical ventilation strategy

Diuresis: Dry Lungs Are Happy Lungs

Rescue Maneuvers for Refractory Hypoxemia

Nutritional support

how do you treat ARDS?

prone positioning

what type of positioning improves VQ mismatch in patients with ARDS?

Extracorporeal Membrane Oxygenation (ECMO)

Most extreme and invasive device for oxygenation / ventilation

Large cannula inserted into large blood vessels

Remove deoxygenated blood, oxygenate and remove CO2 in external device, return oxygenated blood back to the patient

venous-venous ECMO

This type of ECMO bypasses lungs

Used for oxygenation and CO2 removal

venous-arterial

This type of ECMO bypasses lungs and heart

Used for oxygenation, CO2 removal, and cardiac output support

severe COPD exacerbation

Airflow obstruction causing hypercapnic respiratory failure

Clinical findings include expiratory wheezing, increased work of breathing, and elevated CO2 on ABG (could have compensatory metabolic alkalosis)

Improve ventilation for CO2 removal with Bipap vs. Mechanical Ventilator

Bronchodilators

Steroids

Antibiotics

Consider magnesium

how do you treat a COPD exacerbation?

ABG

what test should be ordered upon initiation of Bipap and 1H after initiation in a COPD exacerbation?

acute decompensated systolic heart failure

The most common cause of hospitalization in patients > 65 years old

Hypoxic Respiratory Failure

Inadequate cardiac output +/- hypotension

acute decompensated systolic heart failure

the following signs/symptoms suggest what condition?

Pulmonary edema (rhales on exam) or pleural effusions (diminished breath sounds in bases)

Hypoxia

Elevated JVP

Lower extremity edema

Elevated Brain Natriuretic Peptide (BNP): produced because of ventricle stretching

Decreased perfusion to end-organs: decreased UO, AKI, ALI

heart failure

A complex syndrome characterized by abnormal retention of water and sodium and pathologic changes in one or more of the following:

- Myocardial contractility

- Structural integrity of the valves

- Preload or afterload of the ventricle

- Heart rate

right-sided heart failure

Causes systemic vascular congestion

Signs & Symptoms include jugular venous distension, hepatomegaly / splenomegaly, peripheral edema, and ascites

left-sided heart failure

what is the most common cause of right-sided heart failure?

left-sided heart failure

Causes exertional pulmonary vascular congestion

Signs & Symptoms include orthopnea, paroxysmal nocturnal dyspnea, exertional dyspnea, fatigue, bibasilar crackles or rales on auscultation, gallop, and nocturia

systolic heart failure

heart failure with reduced ejection fraction (EF < 40%)

diastolic heart failure

heart failure with preserved ejection fraction (EF > 50%)

echocardiography

what is the gold standard diagnostic test for heart failure?

Echocardiogram (gold standard)

ECG: LVH common, evidence of prior MI, underlying dysrhythmias

CXR: may show cardiomegaly, cephalization, Kerley B lines, alveolar fluid, or pleural effusions

NT-pro BNP: produced secondary to ventricular stress to modulate sodium and fluid balance

what should be ordered in a heart failure work-up?

Oxygen support with simple oxygen, high flow nasal cannula, CPAP, or Intubation

- CPAP: provides PEEP support to push fluid out of alveoli at a continuous pressure

Goal-Directed Medical Therapy (GDMT) to increase cardiac output

- Diuresis to reduce preload

- Afterload reduction with vasodilators in the acute setting or ARNi or ACE inhibitor

how do you treat acute decompensated heart failure?

beta-blockers and negative inotropes

what medications should be avoided in acute decompensated heart failure?

Intravenous Vasodilator Therapy

Suggested in patients with refractory НF who require reduction in afterload, preload or both.

The use of these agents should be reserved for patients in whom improved hemodynamic function is likely to lead to clinically useful improvements in oxygenation and/or organ perfusion

Furosemide (Lasix) IV injection dosed to response; can dose up to q6h

Furosemide (Lasix) IV infusion

what medications are used for intravenous diuresis in acute decompensated heart failure?

Nitroprusside infusion

Nitroglycerin infusion

ACEi or ARNi once more stable

what medications are used for intravenous vasodilator therapy in acute decompensated heart failure?

Takotsubo syndrome

Pathophysiology: increased myocardial and circulating levels of catecholamines causing a supply and demand problem to the left ventricle seems to be the principal mechanism

Takotsubo syndrome

Typical echocardiogram findings of left ventricular apical ballooning due to stunned myocardium, followed by complete functional recovery over relatively short periods of time in most cases

Coronary angiogram: normal coronaries

Echocardiogram: LV apical ballooning

what should be ordered in a Takotsubo work-up?

Management of Takotsubo and complications based on patient specific echocardiogram findings

how do you manage takotsubo syndrome?

Severe cardiac failure

Pulmonary edema

Cardiogenic shock

Severe mitral regurgitation

LVOT obstruction

Severe arrhythmias

Thromboembolic events

Cardiac arrest

what are complications of Takotsubo syndrome?

pneumothorax

arises when free air enters the potential space between the visceral and parietal lung pleura.

primary pneumothorax

occur without clinically apparent lung disease, either spontaneously or from penetration of the intrapleural space by trauma

secondary pneumothorax

happen in patients with underlying lung disease

pneumothorax

what does this x-ray show?

needle thoracostomy

how do you treat a pneumothorax?

hypertensive urgency

No acute evidence of organ damage

Common causes: Inadequate treatment or non-compliance to treatment

Signs & Symptoms: Often asymptomatic, can present with headache, shortness of breath, epistaxis, or anxiety

Typically restarting meds or adjusting oral meds

Gradual lowering of blood pressure over 24-48 hours

MAP↓~25%

how do you treat a hypertensive urgency?

hypertensive emergency

Severe asymptomatic hypertension (systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥120 mmHg) accompanied by acute target damage

ICU management with IV antihypertensives

Goal: First hour ↓ MAP by ~25% then ↓MAP another 5-15% over next 23 hours

↓ BP enough to reverse/stop end-organ damage

how do you treat hypertensive emergency?

Ischemic stroke: Beware cerebral hypoperfusion, lowering decisions may be based on thrombolytic candidacy

Acute aortic dissection: Rapidly lower BP to target SBP 100-120 mmHg while maintaining adequate perfusion; typically w/in 20 min

what are two exceptions to consider when treating hypertensive emergency?

clots in the deep veins of the lower extremities

where do the majority of pulmonary embolisms originate from?

Hypercoagulable state (exogenous hormones, Factor V Leiden, polycythemia vera)

Venous stasis (bedridden, obesity, cerebrovascular accident, pregnancy, prolonged seated position)

Vascular intimal inflammation or injury (surgical procedures, cancer, oral contraceptives, pregnancy

what is Virchow's triad?

PE

the following clinical features suggest what condition?

•Pleuritic chest pain

•Dyspnea

•Cough

•Hemoptysis

•Diaphoresis

•Tachycardia

•Tachypnea

•Crackels

•Accentuation of the pulmonary component of the second heart sound

•Low-grade fever

spiral CT chest

what is the initial method to diagnose PE?

pulmonary angiography

how do you definitively diagnose a PE?

S1Q3T3 pattern of right heart strain

what pattern is seen on ECG in patients with a PE?

McConnel Sign

what sign is seen on echocardiography in a patient with a PE?

S1Q3T3 pattern

seen in PE

what does this ECG show?

PE

what does this CT scan show?

cor pulmonale

Acute right heart failure / pulmonary hypertension from a pulmonary etiology

PE, severe lung disease, pulmonary arterial hypertension

Heparin is initial anticoagulant of choice to prevent further propagation of clot

how do you treat a hemodynamically stable PE?

Thrombolytics (recombinate tissue plasinogen activator [rt-PA], streptokinase, urokinase)

how do you treat a hemodynamically unstable PE?

IVC filter

how do you treat a PE in patients who cannot tolerate anticoagulation?

Mechanical prophylaxis:

- Early ambulation

- Intermittent pneumatic compression stockings

Pharmacologic prophylaxis:

- Low-dose heparin and low molecular-weight heparin

what is used for DVT prevention for high-risk populations?

cardiac tamponade

Occurs when fluid compromises cardiac filling and impairs cardiac output

Clinical presentation: tachycardia, tachypnea, narrow pulse pressure, jugular vein distention, and pulsus paradoxus, electrical alternans

pulsus paradoxus

an exaggerated drop in systemic blood pressure of greater than 10 mmHg during inspiration

seen in cardiac tamponade

elecrical alternans

beat-to-beat alternating amplitude of the QRS complexes (and more subtly of other waveforms) that reflects swinging of the heart in the pericardial fluid

seen in cardiac tamponade

Muffled heart sounds, jugular venous distention, and hypotension

seen in cardiac tamponade

what is Beck's triad?

pericardiocentesis

how do you treat cardiac tamponade?

electrical alternans

what does this ECG show?

pulsus paradoxus

what does this show?

pathophysiology of coronary heart disease

as plaque matures, a fibrous cap forms over them

the plaques with defective or broken caps are most prone to rupture

the lesions alone may distort vessels to the point that they are occluded, but it is usually the rupture or ulceration of plaques that triggers thrombosis, blocking blood flow

rise or fall in cardiac biomarkers

supportive evidence in the form of typical symptoms

suggestive ECG changes

imaging evidence of new loss of viable myocardium or new regional wall motion abnormality

how do you diagnose MI?

true

true/false: a negative ECG does NOT rule out ACS

type I MI

caused by acute atherothrombotic coronary artery disease and usually precipitates by atherosclerotic plaque disruption (rupture or erosion)

type 2 MI

caused by a mismatch between oxygen supply and demand with or without underlying coronary artery disease

mechanisms include coronary dissection, vasospasm (cocaine), emboli, microvascular dysfunction, severe shock states

rest angina

new onset angina that markedly limits physical activity

increasing angina that is more frequent, longer duration, or occurs with less exertion than previous angina

chest pain or discomfort radiating to the jaw, left shoulder, or arm

atypical symptoms include dyspnea, nausea, diaphoresis, and syncope

S4

what are signs & symptoms of acute coronary syndrome?

EKG

Cardiac enzymes (troponin, CK, and CK-MB)

ECHO

NT-pro BNP

CMP

CBC

PT/INR, PTT

what should be ordered when working up acute coronary syndrome?

troponin

a protein found in the muscle of the heart, that is not normally found in the blood

when heart muscles become damaged, this is sent into the bloodstream

as heart damage increases, greater amounts of this are released in the blood

new LBBB

peaked T waves

transient ST-segment depression during anginal episodes

nondiagnostic T-wave inversions

ST-segment elevation

pathological Q waves

what EKG findings are seen in ACS?

coronary angiography

what is the gold standard for evaluating ACS and occlusive disease?

stable angina

normal ECG

normal troponin levels

unstable angina

ECG can be normal or show inverted T waves, or ST depression

normal troponin levels

NSTEMI

ECG can be normal or show inverted T waves or ST depression

Troponins are elevated

STEMI

ECG shows hyperacute T waves or ST elevation

Troponins are elevated

troponin

what is the preferred test for evaluation of patients with suspected MI?

Nitroglycerin first

Morphine if ongoing pain

how do you relieve ischemic pain in NSTEACS?

nitroglycerin

can reduce the symptoms of chest discomfort and HF as well as treat hypertension

patients on phosphodiesterase inhibitors in previous 24 hours

what are contraindications to nitroglycerin?

oxygen (if SpO2 < 94%)

statin therapy

beta blockers (if no contraindications)

what anti-ischemic therapies should be implemented in patients with ACS?

high intensity statin

Atorvastatin 80 mg daily or Rosuvastatin 40 mg daily

what is the dose of statins given to all ACS patients?

heart rate < 50 bpm

decompensated heart failure

shock (SBP < 90 mmHg)

heart blocks (without pacemaker)

active asthma or COPD exacerbation

active cocaine use

what are contraindications to beta-blockers?

initial dose 325 mg followed by 81 mg daily of non-coated aspirin

what dose of aspirin is given to patients with NSTEACS?

true

true/false: all nonsteroidal anti-inflammatory drugs (except aspirin) should be discontinued in NSTEACS due to increased risk of major adverse cardiac events

Platelet P2Y receptor blocker

used in combination with aspirin in all patients with NSTEACS

Clopidogrel, Ticlopidine, Ticagrelor, Prasugrel, and Cangrelor are what type of drug?

TIMI risk score

estimates your risk of mortality at 14-days after MI

GRACE scoring system

estimates admission to 6-month mortality for patients with ACS

uses 8 parameters to predict death and MI in hospital and at 6 months