Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "Principles of Surgery (POS) Critical Care Review D.Kubelik University of Ottawa POS Lecture Series 2012 Adapted from D.Kim."— Presentation transcript:

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

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

12 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

13 Treatments

14 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

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

16 Frank-Starling

17 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

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

19 Hemoglobin-O2 Dissocation Curve

20 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

21 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

22 DO2-VO2 Equations

23 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

24 CVP and PCWP

25 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

26 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

27 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

28 CO2 metabolism

29 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

30 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

31 Compliance & Resistance

32 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%

33 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

34 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

35 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

36 PFTs

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

38 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

39 Trauma

40 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?

41 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

42 32yo female jumper from 10 th floor head and extremity injuries apneic in ED By which method is a definitive airway provided for this patient?

43 a) orotracheal intubation b) nasotracheal intubation c) cricothyroidotomy d) needle cricothyroidotomy \

44 22 yo male automobile fire carbonaceous sputum, stridor failed nasotracheal intubation O2=97% Prior to orotracheal intubation, what step(s) is/are correct?

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

46 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?

47 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

48 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?

49 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

50 24 yo male unrestrained driver MVC hypoxic despite O2 CXR - bilateral chest infiltrates Which of the following in the most likely diagnosis?

51 a) bilateral pneumonia b) ARDS c) aspiration pneumonia d) atelectasis e) pulmonary contusion

52 Which of the following modalities in the most important for identifying patients at risk for complications from myocardial contusion?

53 a) serial CK and TnI b) ECG c) echo d) spiral CT e) cardiac angio

54 40 yo male stab to left 7 th intercostal in the anterior axillary line clinically stable, clear BS bilat CXR - no ptx, no hemo Which of the following statement(s) is/are true?

55 a) absence of hemo/pneumo indicates that the pleural cavity was not entered b) absence of hemo/pneumo rules out intraabdominal injury c) if the pat. is to have GA, he must first undergo a left sided chest tube insertion d) further evaluation should be carried out to rule out intraabdo. injury

56 30 yo male stab wound to right mid- infraclavicular region weak pulse in bus 10 minutes ago now, no pulse or BP in ED with reactive pupils What is the initial surgical approach of choice?

57 a) median sternotomy b) right sided cervical incision c) right sided clavicular incision d) right anterolateral thoracotomy e) left anterolateral thoracotomy

58 22yo female stab to left 5 th ICS in MCL BP=70/40; HR=140; RR=35 JVD-normal; trachea midline; muffled HS; decreased BS on the left Which of the following is/are possible diagnosis?

59 a) pericardial tamponade b) massive left hemo c) tension ptx d) flail chest e) a, b, and c

60 28yo unrestrained driver in MVC VSS and LUQ tenderness with no peritonitis What is the next step in management?

61 a) ex lap b) diagnostic peritoneal lavage (DPL) c) admit for obs d) CT abdo/pelvis e) focused assessment using sonography for trauma (FAST)

62 47yo male high speed MVC VSS, multiple rib fractures and L femur # PCXR (insert) Which of the following is/are most appropriate for evaluation?

63 a) admit, observe, repeat CXR 6-8 hrs. b) immediate aortography c) CT thorax with contrast d) L anterolateral thoracotomy e) b and c

64 Which of the following is/are indications for emergent angiography in hemodynamically unstable patients with a pelvic ring fracture?

65 a) grossly negative findings on DPL b) micro. positive findings c) grossly negative findings on DPL and continued bleeding requiring ongoing transfusion d) stable patient with an expanding hematomta

66 Regarding liver trauma, which of the following statements is/are true?

67 a) NOM is Rx of choice in stable pt. with isolated hepatic injury b) the Pringle maneuver can be performed for up to 90 min. without ischemic sequelae c) subcapsular hematomas discovered intraop should always be explored d) finger fracture technique for deep lacs is ineffective e) intraop packing, rapid closure, and resuscitation in the ICU has led to an increased mortality

68 27yo male suffers severe blow to head VSS, breathing spontaneously opens eyes to voice; mumbles words; withdraws to pain Which of the following is/are indicated in the initial evaluation and stabilization?

69 a) CT head b) ETT and hyperventilation c) ICP monitoring d) burrhole on the right side e) A, B, C

70 Which of the following is/are true re: peripheral arterial injuries?

71 a) all patients have diminished or no pulses distal to the extremity b) if the injury cannot be repaired primarily, a prosthetic interposition graft should be used c) all patients with post. knee dislocations should undergo popliteal angio d) compartment syndrome is a contraindication to angiography e) completion angio. is not necessary after the insertion of an interposition graft if distal pulses are present

72 Critical Care

73 Cardiac Physiology

74 PAWP ~ Left atrial pressure CVP ~ Right atrial pressure

75 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

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

77 Classifying Shock Hypovolemic Cardiogenic Obstructive Distributive (Endocrine) Can have cardiogenic or distributive components

78 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

79

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

81 Treatments

82 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

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

84 Frank-Starling

85 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

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

87 Hemoglobin-O2 Dissocation Curve

88 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

89 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

90 DO2-VO2 Equations

91 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

92 CVP and PCWP

93 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

94 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

95 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

96 CO2 metabolism

97 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

98 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

99 Compliance & Resistance

100 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%

101 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

102 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

103 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

104 PFTs

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

106 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

107 Questions?


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

Similar presentations


Ads by Google