Acute & Critical Care Medicine

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166 Terms

1
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Difference between crystalloids and colloid fluids

crystalloids: most of volume does not remain in the intravascular space (inside blood vessels) but moves into extravascular/interstitial space

colloids: primarily remain in intravascular space and increase oncotic pressure

2
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Examples of crystalloids:

5% dextrose (D5W)

0.9% NaCL (NS)

Lactated Ringers (LR)

Plasma-Lyte A

3
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Examples of colloids

albumin 5%, albumin 25%

Hespan (hydroxyethyl starch, dextran

4
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Colloids provide (smaller/larger) intravascular volume than crystaloids

larger

5
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T/F: Colloids are more expensive and have not shown a clear clinical benefit over crystalloids

true

6
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Fluids most commonly used for volume resuscitation in shock states

NS and LR

7
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lactated ringers contains:

NaCl, KCl, CaCl2, Na-lactate (which is converted to bicarbonate)

8
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The most commonly used colloid ______ is specifically useful when there is _____ such as in conditions like _____

albumin

useful specifically when there is significant edema like in conditions like cirrhosis

9
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T/F: Albumin can be used as a nutritional supplementation when serum albumin is low

FALSE this is now how to raise albumin

10
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Hespan starch has a boxed warning for ____ and should only be used if other treatments are unavailable

boxed warning for mortality

11
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Hyponatremia is usually not sympotmatic until:___ where symptoms can be

<120

symptoms can be headache, confusion, gait disturbances to seizures, coma

12
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3 types of hyponatremia based on osmolality and their preferred treatment

hypotonic hypervolemic hyponatremia: (fluid overload): treat w/ diuresis and fluid restriction

isovolemic: diuresis, stopping offending agents, demeclocycline for SIADH off-label

hypovolemic:(caused by diuretics) stop intake of hypotonic solutions, give hypertonic (3%) sodium chloride IV

13
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Typical treatment goal of sodium correction is ______

4-8 mEq/L/24H

14
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Correcting sodium more rapidly than ______ can cause ________

more rapidly than 12 mEq/L/24H

can cause osmotic demyelination syndrome or central pontine myelinolysis (leading to paralysis, seizures, death)

15
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Treatment for SIADH, hypervolemic hyponatremia

conivaptan and tolvaptan (AVP receptor antagonists)

16
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tolvaptan drug class

arginine vasopressin receptor antagonists (AVP antagonists)

17
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Do not use Samsca beyond ________

30 days

(tolvaptan)

18
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T/F: tolvaptan must be initiated and re-initated in the hospital

true (boxed warning)

19
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boxed warning on Samsca

(tolvaptan)

initiated and re-initiated in a hospital

overly rapid correction of hyponatremia (>12 mEq/L/24H is assoc. w/ ODS (life-threatening)

20
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warnings and side effects with tolvaptan

hepatotoxicity

SE: thirst, nausea, dry mouth, polyuria

21
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Tolvaptan is administered ___ for no more than ____ (due to ____)

PO (tablet)

no more than 30 days due to hepatotoxicity

22
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hypovolemic hypernatremia is typically caused by:

dehydration, vomiting, diarrhea (treat w/ fluids)

23
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hypervolemic hypernatremia is caused by

intake of hypertonic fluids (treat w/ diuresis)

24
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isovolemic euvolemic hypernatremia is usually caused by:

Diabetes insipidus which can decrease ADH

(it is treated w/ desmopressin)

25
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a drop of ____ below 3.5 mEq/L represents a total body deficit of ______ in potassium

a drop of 1 mEq/L in serum K below 3.5 represents a deficit of 100-400 mEq

26
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T/F: The oral route is preferred for potassium when feasible

true

27
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Max infusion rate of potassium and max concentration

10 mEq/hr, max concentration of 10 mEq/100mL

28
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T/F: IV potassium should be adminstered undiluted or via IV push

False: These administration routes are LETHAL

NEVER administered undiluted or via IV push

29
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______ is necessary for potassium uptake

magnesium

30
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When someone is hypokalemic and has low magnesium, _____ should be corrected first

magnesium should be replaced first (M comes before P in the alphabet)

31
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Magnesium replacement via _____ is recommended

IV magnesium sulfate

32
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symptoms of hypomagnesium

seizures, arrx

33
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T/F: Hypophosphatemia is considered severe and is usually symptomatic

True

34
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Hypophosphatemia is replaced via ____

IV phosphorus

35
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Uses for IVIG

MS, myasthenia gravis, Guillain-Barre syndrome, immunodeficiency conditions

36
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IVIG can impair response to

vaccination

37
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Boxed warning with IVIG products

acute renal dysfunction: is more likely w/ products stabilized w/ sucrose

thrombosis can occur even without RFs

38
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Octagam and Privigen are brans of

IVIG products

39
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When dosing IVIG, remember:

use a slower infusion rate in renal and CV disease patients

do not freeze, shake or heat

40
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side effects of immunoglobulin

infusion reaction (facial flushing) chest tightness, fever, chills, hypotension - slow/stop infusion

(may use premedication or slower titration)

41
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Score used to estimate ICU mortality risk

APACHE II

42
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most vasopressors work by stimulating _____ which causes _____

stimulating alpha receptors causing peripheral vasocontriction (think pressing down on the vasculature)

this increases SVR) which increases BP

43
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vasopressors that stimulate beta receptors can increase ______

HR and CO

44
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Phenylephrine is a ______ that increases _______ without _____

pure alpha-agonist that increases SVR without increasing HR

45
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Mixed alpha- and beta-agonists include

epinephrine and norepinephrine

46
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mixed alpha- and beta-agonists increase :

SVR, CO, and HR

47
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dopamine is a natural precursor of

norepinephrine

48
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At a low dose (____-____) dopamine is a _____

Low (renal) dose: 1-4mcg/kg/min

dopamine is a dopamine-1 agonist

49
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at a medium dose (__-____) dopamine is a ____

medium dose: 5-10 mcg/kg/min

dopamine is a beta-1 agonist

50
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at a high dose: (__-____) dopamine is a _____

high dose: 10-20 mcg/kg/min

dopamine is an alpha-1 agonist

51
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Dopamine from low to medium to high dose becomes a

dopamine-1 agonist, beta-1 agonist, alpha-1 agonist

(DBAA)

52
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Vasostrict drug class

(vasopressin)

vasopressin receptor agonist

known as arginine vasopressin (AVP) and antidiuretic hormone ADH

53
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levophed drug class

(norepinephrine)

alpha-1 agonist > beta-1 agonist activity

54
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all vasopressors are _____, when administered IV. This can be treated w/ ______

all vasopressors are vesicants

extravasation can be treated w/ phentolamine

55
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Extravasation from vasopressors can be treated with

phentolamine

56
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Epinephrine IM injection (epipen) strength or compounding IV products is:

1mg/mL (1:1,000)

57
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Epinephrine used for IV push is

0.1mg/mL, 1:10,000 ratio strength

58
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Side effects of Vasopressors

arrx, tachy, necrosis (gangrene), bradycardia, phenylephrine, hyperglycemia (epi)

59
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T/F: Patients on vasopressors should be monitored continuously for BP and MAP

true

60
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Phentolamine drug class

alpha-1 blocker (antagonizes effects of the vasopressor

61
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what to do if extravasation occurs?

stop infusion, don't dc needle/cannula, don't flush the line, aspirate the drug

phentolamine can be given

NG ointment is sometimes used if phentolamine is unavailable

62
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Effectiveness of nitroglycerin for myocardial ischemia or uncontrolled HTN may be limited to ____ due to ______

24-48H due to tachyphylaxis (nitrate)

63
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Nitroprusside drug class

mixed (equal) arterial and venous vasodilator at al doses

64
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T/F: Nitroprusside has a greater effect on BP than Nitroglycerin

true

65
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T/F: Nitroprusside can be used in active myocardial ischemia

False: should NOT be used here because it can cause blood to be diverted away from diseased coronary arteries (coronary steal)

66
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metabolism of nitroprusside results in

thiocyanate and cyanide formation

67
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_______ can be administered to reduce the risk of _____ toxicity from nitroprusside

hydroxocobalamin can reduce the risk of thiocyanate toxicity or treat cyanide toxicity

68
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Sodium thiosulfate is used for

cyanide toxicity

69
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Drug used for cyanide toxicity

sodium thiosulfate (nithiodote (+sodium nitrite)

70
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Nitroglycerin is a ____ at low doses_ and a _______ at high doses

low doses: venous dilator

high doses: arterial vasodilator

71
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T/F: Nitroprusside must be further diluted

true

72
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Dilute nitroprusside with ____

D5W

73
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Pharmacists should be warned that nitroprusside can increase

increase ICP

74
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Contraindications to NG

SBP <90, use with PDE-5 inhibs

75
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NG requires a ____ container

non-PVC container (exe. glass, polyolefin)

76
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There is increased risk of cyanide/thiocyanate toxicity in_____- with nitroprusside

renal and hepatic impairment

77
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Nipride requires ____ during administrations

light protection

78
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Only use ___ solutions with Nipride, as a blue color indicates _____

clear solutions

blue color indicates degradation to cyanide

79
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Inotropes work by

increasing contractility of the heart

80
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Dobutamine is a ______ that works by increasing ____

dobutamine is a beta-1 agonist

works by increasing HR and force of contraction (therefore increasing CO)

(also has weak beta-2 and alpha-1 agonism but is less important)

81
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Milrinone is a _____ that produces ____ effects

it is a phosphodiesterase-3(PDE-3)inhibitors in cardiac and vascular tissue

produces inotropic effects (vasodilation)

82
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Vasodilators include:

nitroglycerin, nitroprusside

83
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inotropes include:

Dobutamine

Milrinone

84
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notes regarding dobutamine

may turn slightly pink due to oxidation, but potency is not lost

85
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Shock usually is characterized by:

hypoperfusion (usually from hypotension): <90SBP or MAP<70

86
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4 types of shock

hypovolemic (exe. hemorrhagic)

distributive (ex. septic, anaphylactic)

cardiogenic (ex. post-myocardial infarction)

obstructive (ex. massive pulm. embolism)

87
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First line treatment for hypovolemic shock

fluid resuscitation with crystalloids when it is not caused by hemorrhage

blood products when there is hypovol shock due to bleeding

vasopressors may be indicated if they do not respond, but will not be effective unless intravascular volume is adequate

88
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T/F: If the volume cannot be correct in a patient with hypovolemic shock, vasopressors can be given

False: Vasopressors will NOT be effective unless intravascular volume is adequate. Vasopressors can be given if patients don't respond to initial crystalloid/blood product therapy (fluid challenge)

89
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Sepsis and anaphylaxis are examples of _____ shock

distributive

90
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sepsis is defined as _______ caused by ______

life threatening organ dysfunction

caused by dysregulated host response to infection

91
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T/F: NEWS and SIRS criteria are recommended over the qSOFA assessment for Sepsis

true

92
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In sepsis, target a MAP of _____

65 or higher

93
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MAP equation

MAP = [(2 x DBP) + SBP]/3

94
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General principles in treating sepsis

target MAP of 65+mmHg

optimize preload w/ IV crystalloids (LR preferred)

alpha-1 agonist to increase SVR (peripheral vasoconstriction)

beta-1 agonist to increase contractility and CO

(squeeze the pipe (alpha 1) and kick the pump (beta 1)

95
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Septic shock is:

sepsis in presence of persistent hypotension, requiring vasopressor to maintain MAP 65+

(and serum lactate 2+ despite adequate fluid resus)

96
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Bundles in surviving sepsis campaign include interventions like:

early administration of broad-spectrum Antibiotics

fluid resuscitation w/ IV crystalloids

97
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Vasopressor of choice in septic shock

norepinephrine (levophed)

98
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Commonly used in addition to norepinephrine in septic shock

vasopressin

99
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Cardiogenic shock is:

acute decompensated heart failure (ADHF: worsening HF sx)

+ hypotension and hypoperfusion also present

100
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Drugs that can worsen HF/cause ADHF

negative inotropes (non-DHP CCBs

drugs that cause NSAIDS

cardiotoxic drugs