Download FCCS PRE TEST AND POST TEST EXAM 2024-2025 and more Exams Nursing in PDF only on Docsity! 1 | P a g e FCCS PRE TEST AND POST TEST EXAM 2024-2025 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+|NEWEST|GUARANTEED PASS |LATEST UPDATE A 75-year-old man with a long history of smoking, chronic lung disease, and treatment noncompliance is brought to the emergency department by his daughter. He has had progressive dyspnea. He is awake, alert, and in moderate distress, with the use of accessory muscles during inspiration and expiration and a respiratory rate of 30 beats/min. There are audible expiratory wheezes. Which of the following pharmacologic treatments should be initiated? A. Inhaled beta2-agonist B. Aerosolized racemic epinephrine C. Transtracheal lidocaine D. N-acetylcysteine A A 65-year-old woman is admitted with pulmonary edema due to acute diastolic left ventricular failure. She is alert and oriented but has a respiratory rate of 30 breaths/min and a room air SpO2 of 88%. On examination, she has 4 cm jugular venous distention and end-inspiratory crackles in her lung fields bilaterally. Room air arterial blood gas analysis shows: pH 7.28, PCO2 48 mm Hg, and PO2 58 mm Hg. Along with diuresis and antihypertensive therapy, she is placed on bilevel noninvasive ventilation with an inspiratory positive airway pressure (IPAP) of 12 cm H 2O and an expiratory positive airway pressure (EPAP) of 8 cm H2O delivered via full face mask with FIO2 0.5. Two hours after initiating noninvasive positive pressure ventilation (NPPV), the bedside nurse calls the physician to reassess the patient. The 2 | P a g e patient is now agitated and fails to follow commands. SpO2 is now 85%. Repeat arterial blood gas analysis shows: C An 18-year-old, 55-kg (121-lb) woman has just been intubated for an acute asthma attack. She has been sedated and paralyzed in order to facilitate ventilation. Arterial blood gas analysis immediately before intubation revealed: pH 7.08, PCO2 75 mm Hg, and PO2 63 mm Hg on FIO2 0.4. On bagging, diffuse high- pitched wheezes are heard. Which of the following is the most appropriate initial ventilator mode for this patient? A. Continuous positive airway pressure B. Pressure support ventilation C. Assist control volume ventilation D. Assist control pressure ventilation C A 56-year-old man presents to the emergency department with a three-day history of fever, shaking chills, cough, and sputum production. He was previously in good health and takes only amlodipine for a history of hypertension. In the emergency department, his heart rate is 130 beats/min, respiratory rate 32breaths/min, blood pressure 80/40 mm Hg, temperature 38.8°C (102°F), and oxygen saturation 92% on 6 liters of oxygen by nasal cannula. Pulmonary examination demonstrates crackles and bronchial breath sounds in both lower lobes. A chest radiograph shows multilobar consolidations. Although awake and alert, he appears visibly distressed and has marked accessory muscle use. Apart from antibiotics and resuscitation for sepsis, which of the following is the next best step for management of his respiratory failure? A. Trial of noninvasive mechanical ventilation by face mask B. Intubation and initiation of invasive mechani B A 56-year-old man is admitted to the ICU for pneumonia. He is intubated, with the following settings: assist control, tidal volume 550 mL, respiratory rate 12 breaths/min, positive end-expiratory pressure 5 cm H2O, FIO2 1.0. Vital signs are: temperature 38.7°C (101.6°F), heart rate 122 beats/min, respiratory rate 20 breaths/min, blood pressure (BP) 88/46 mmHg, SpO2 97%. A central venous line and arterial line have been placed. He has been started on broad-spectrum antibiotics. Which of the following is a clinical indicator that he would benefit from further fluid resuscitation? A. Heart rate persistently greater than 90 beats/min B. Passive leg raise resulting in at least 20% increase in systolic BP C. Urine output of less than 0.5 mL/kg/hour D. Systolic BP less than 90 mm Hg B 5 | P a g e C Which of the following would not be an expected laboratory finding associated with preeclampsia? A. Alanine aminotransferase level of 60 U/L B. Normal glucose level C. Decreased fibrinogen level D. Normal bilirubin level C Which of the following parameters may be a late sign of cardiovascular disturbance signaling failure of the compensatory mechanisms? A. Tachycardia B. Bradycardia C. Hypotension D. Hypertension C Investigative tests should be based on the patient's history and physical examination as well as on previous tests. Which of the following is one of the most important indicators of critical illness? A. Respiratory acidosis B. Metabolic acidosis C. Elevated creatinine D. Hyponatremia B A 22-year-old man is brought to the emergency room after falling from a horse. He is awaiting transfer to another facility. He has a chest contusion and a non-displaced femur fracture. He is in spinal motion restriction with a cervical collar and long backboard. He has worsening respiratory distress and hypoxemia requiring endotracheal intubation. Which of the following modifications of the manual assisted ventilation technique is appropriate? A. Place an oral airway one size larger than usual. B. Add additional downward pressure on the face mask once it is sealed. C. Use a jaw thrust technique in place of neck extension. D. Increase the tidal volume with each manual assisted breath. C Which of the following anatomic features is most likely to contribute to difficulty in maintaining a patent airway in a supine patient? 6 | P a g e A. Edentulous mandible B. Posteriorly displaced tongue C. Deviated nasal septum D. Anteriorly displaced thyroid cartilage B An elderly patient is on the medical ward for respiratory distress. Which of the following is correct regarding airway assessment? A. Laryngeal displacement toward the chest during inspiration occurs only with upper airway obstruction B. Chest rise with inspiration indicates an adequate tidal volume C. Unilateral absent breath sounds on auscultation is a tension pneumothorax D. Complete airway obstruction is likely when chest retraction and movement is present, but there are no breath sounds D An 82-year-old man who awoke with chest pain in the morning is being evaluated in the emergency department. He is alert and oriented. Shortly after being placed on a cardiac monitor in normal sinus rhythm with ST segment elevations, he becomes unresponsive and develops ventricular fibrillation. Which of the following initial interventions is most appropriate for this patient? A. Do not initiate treatment because, due to his age, he probably has a do-not-resuscitate order on file. B. Attempt to contact the family before treating to discuss the level of intervention. C. Start cardiopulmonary resuscitation while preparing to defibrillate. D. Start bag-mask-valve ventilation while preparing to intubate. C Which of the following is the purpose of cardiopulmonary resuscitation? A. To reverse symptomatic bradycardia in an ICU patient who is on multiple vasoactive infusions B. To reverse sudden cardiac death in a patient who is in the palliative care unit C. To prolong the life of a patient who has a do-not-resuscitate order on file to allow time for family to arrive D. To reverse sudden, unexpected death from a reversible disease process or iatrogenic complications D Hyponatremia - indications for 3% NS? Seizures or AMS 7 | P a g e What speed/rate can Na be correct in hyponatremia? 8 mEq/24 hours 43 yo m with hx of CAD comes with left hemiparesis x 1 hour. CT shows no bleed. What do we do? Administer TPA/TNK 22 yo m after MVA; incomprehensible sounds, no eye opening to painful stimuli, CT scan shows increased ICP and subdural bleed; what is the first thing we do? Elevate head of bed to 30-45 degrees Male presents with no breath sounds and tracheal deviation to the left side, what do we do? 16 gauge needle cdecompression BP 86/52, HR 126, RR 29; what class of shock is this? Three/ Progressive Stage Male after MVA; FAST shows bleeding, on way to OR his BP tanks, what do we do to resuscitate? 1:1:1 RBCS, platelets, FFP male presents after MVA in cervical spine collar; while waiting for xray the SpO2 drops to 85%, left pupil is larger than right, he does not respond, only grunts, moves limbs to pain; what do we do? intubate with inline intubation NSTEMI or STEMI what do we want our SpO2 to stay above? > 94% Who should go to cath lab IMMEDIATELY with NSTEMI? If they have shock with NSTEMI =immediate cath lab/CABG After STEMI, what drug has been shown to decrease risk of mortality? ACE inhibitors Loose stools after treatment for UTI with antibiotics; MRI shows pancolitis, what is the tx? IVF, metronidazole, PO Vanco (It's CDIFF) Hospital day 14, pt with tachycardia; culture from central line = gram + cocci what do we do? Remove with line and treat with vanco Fever and headache with period of confusion in 20 year old patient; what is the likely cause? How do we treat? 10 | P a g e 45 yo male, vent for ARDs d/t aspiration pneumonia; his vent settings are AC mode, tidal volume 5 mL/kg, RR 20, PEEP 22, peak airway pressure 40, plateau 35, FiO2 100% PH 7.34 PaO2 88 What do we do? Lower PEEP to 18 to Lower pressure inside lung 72 year old male with CHF with accessory muscle use is awake and alert RR 34 BP 120/80 HR 120 SpO2 90% on 8L CXR shows bialteral infiltrate consistent with CHF ABG 7.34 pH, 64 paO2, 50 paCO2 Treamtent? He needs pressure to get air in, so Bi-pap because he is alert and responsive with stable BP (other options are CPAP, vent) What decreases SVO2 Decreased o2 delivery Increased o2 consumption Male presents with SOB and femur fracture Temp 100.4 HR 144 RR 30 BP 100/70 SPO2 92% Hgb 8 SVO2 52% How do we treat his hypotension? Fluid bolus How do we treat coughing during intubation? Lidocaine spray (because coughing increases ICP) 11 | P a g e Management of unstable angina/NSTEMI MONA 1- analgesic/anti-ischemia: morphine, nitrates, oral beta blocker to slow HR and decrease its demand 2- ASA 3- heparin 4 -serial cardiac markers (CKMB/trops) Consider reperfusion therapy What is the initial tidal volume a vent should be set at? 6 mL/kg What does the plateau pressure need to be below <30 If too high it is forcing too much air, so lower the tidal volume or respiratory rate What is the normal inspiratory to expiratory ratio 1 : 2-3 Candidates for NPPV must be Alert, cooperative Hemodynamically stable Able to control airway secretion Able to coordinate with machine What settings should NPPV be initiated at? CPAP has to start at 8 BiPAP has to start at 8 inspiratory/4 expiratory What does a high inspiratory plateau pressure indicate? Alveolar distension, which can cause a pneumothorax How to manage high autopeep Disconnect pt from vent and push on chest to get air out, then reconnect and either decrease tidal volume or RR so they have time to exhale What should PEEP start at on vent setting? 5-8 How is body weight predicted? 12 | P a g e 45.5 + 2.3 (ht in inches -60) If a patient is on a ventilator at FiO2 100% at PEEP of 24 and they are still hypoxic, what is our next step? Then what? Then what? Increase the inspiratory time, to make the ratio 3:1 inspiratory:expiratory If still hypoxic do prone position for 18 hours, 6 off If still hypoxic do ECMO At FiO2 of 30% what is the highest the PEEP can be? At 40% At 50% At 60% At 70% At 80 % At 90% At 100% 30%- 5-8 40%- 8 50%- 10 60%- 12 70%- 14 80%- 16-18 90%- 18-22 100% 22-24 What is the most important sign in a critically ill pt? Why? Tachypnea Indicates metabolic acidosis (often w/ respiratory alkalosis compensation) A pt misses dialysis for a few days and comes in with fluid overload. He's tachycardic and tachypneic. On physical exam, you find JVD, pulsus paradoxus (20 mmHg drop during inspiration), and HoTN (80/40) with distant, muffled heart sounds. Lungs are clear to auscultation. What is the dx? Cardiac tamponade; obstructive shock If a pt has a thyromental distance of 2 cm, what can you expect about their airway? Difficult airway w/ an anteriorly displaced larynx A COPD pt comes in with difficulty breathing. He then becomes apneic and unresponsive. How would you ventilate this pt? BVM 15 | P a g e What is the best tx for this pt? Non-invasive BiPAP. A pt comes in w/ a femur fx and a rod is placed. Post-op he develops dyspnea and fever. HR 140, RR 30, SpO2 92% on non-rebreather. He is transferred to the ICU where you intubate, place a central line, and start resuscitating him. Hb 8.2, lactate 3.2, SVO2 is 52%. Why is his SVO2 low? How can we improve it? Decreased O2 delivery and increased consumption. (normal is 65-70) Administer packed RBCs - 1U of blood will change his Hb from 8.2 to 9.2. O2, fluid, and VT would not work. A young pt after an MVA comes to the ER hypotensive and tachycardic. CXR is clear. He has a contusion on his chest wall and torso. He is unconscious. What will give you the best insight on what is causing his shock? Hb SCV Urine Output FAST exam FAST exam 41 y/o pt in the SICU following debridement of b/l lower extremities for necrotizing fasciitis is intubated on AC. Temp 102, HR 116, RR 16, BP 92/46. ABG shows pH 7.23, PO2 133, PCO2 38, Na 139, K 3.7, Cl 102, Bicarb 16, lactate 4. Dx is metabolic acidosis w/ anion gap d/t infection. What is the most appropriate intervention? Increase VT Continue resuscitation Decrease RR Administer bicarb Continue resuscitation. Don't need to increase VT bc the pt doesn't have respiratory acidosis. If you decrease the RR, the pt will go into respiratory acidosis. A pt has obstructive uropathy. A catheter is placed d/t the obstructive kidney injury. After the cath is placed, he has massive diuresis to the point where he is hypotensive, tachy, and lactate is 2x the ULN from decreased perfusion. How would you correct this? 16 | P a g e Fluids - LR When treating hyponatremia, what is the first thing to assess? When do you give 3% NaCl? How do you correct it? 1. fluid status 2. seizures or changes in mental status 3. slowly, 8-12 meq over 24 hr What are the classifications of hemorrhagic shock? I: <15%; HR <100, BP normal, RR normal II: 15-30%; HR >100, BP normal, RR 20-30 III: 30-40%; HR >120, BP low, RR 30-40 IV: >40%; HR >140, BP low, RR >40 An 84 y/o pt fell down the stairs. He is moaning and crying. He has a C-collar in place. His neck is painful and he has bruising on his face. He is tachy but BP is okay. You administer 2L O2 bc SpO2 was 92%. Shortly after he deteriorates, becoming altered and then comatose. His left pupil > the right. He is herniating from cerebral edema. How do you treat him? Intubate and ventilate, maintaining c-spine precautions. Administer mannitol. A pt comes in with several cardiovascular RFs: elderly, DM, and HTN. He is having chest pain, SOB, and is diaphoretic. What diagnosis do you need to re-perfuse him immediately? STEMI What is the most appropriate management for both STEMI and non-STEMI? nitro if bp >80 morphine q 30 min bb oxygen if sats are <94% Oxygen Which NSTEMI needs to be sent to the cath lab immediately? NSTEMI w/ shock Which medication improves outcomes for pts with STEMI? ACE-I Give if BP is stable. It decreases LV remodeling and decreases afterload. 17 | P a g e A 70 y/o pt has been hospitalized for 15 days. He had a cholecystectomy and abscess formation which was tx appropriately. He has a central line in the right IJ. The site looks visibly infected, and he has a fever, is tachy, and hypotensive. WBCs are high. Blood culture and initial gram stain reveals G(+) cocci. What is the dx? What is the MC pathogen? What is the tx? 1. line-related infection 2. coag (-) staph epidermis 3. vanco + zosyn + ceftriaxone if MRSA: vanco + ceftriaxone if MSSA: zosyn + ceftriaxone What is the tx for meningitis? young pt: ceftriaxone + vanco > 50 pt: add ampicillin A chemotherapy pt becomes septic. You suspect a neutropenic fever. What is the tx? broad spectrum abx (vanco/zosyn) obtain blood, urine, and sputum culture CXR + CT What is the tx of hyperkalemia? calcium gluconate + insulin + dextrose bicarb, kayexalate, albuterol definitive tx: dialysis How do you manage DKA? Check potassium Multiple L bolus via at least 2 peripheral IVs Insulin infusion, 0.1U/kg/hr until sugar reaches 250 mg/dl Switch NS to D5W Once anion gap is closed, administer long-acting insulin 1 hr prior to d/c infusion A 70 y/o pt with COPD comes in with an exacerbation. He is rapidly becoming more hypoxic. To rule out PE, what test should you order? CT 20 | P a g e drugs: -lido p 28 a what periintubation drug has been shown to blunt response of increasing ICP in someone whith a head injury? lidocaine (1-1.5 mg/kg) what is goal temp ranges for targeted temperature management? what are the 2 potential big SEs? 32 to 36 C for at least 24 hours in comatose (GCS<8) patients following ROSC SEs: coagulopathy, increased risk of infxn what percentage of normal CO does chest compressions produce? 1/3 what is the goal CO2 following arrest? 38-42 (normocapnea) what are teh 3 broad types of respiratory failure? PNA is most often associated with which one? drug OD? CHF? COPD? dead space ventillation? hypoxemic (PaO2 <60), hypercapneic (PaCO2 >50), mixed hypoxemic (although can be mixed) hypercapneic hypoxemic mixed hypercapneic define shunt physiology? waht is at the other end of the VQ spectrum? no V, still adequate Q dead space what ratio is most useful in tracking hypoxia over time? P:F ratio, PaO2 and FiO2 normal is 300-500 define minute ventilation (VA) VA = RR* (VT - VD) VD = dead space 21 | P a g e define paradoxical breathing? why does it occur diaphragm is flaccid b/c of fatigue and moves upward during inspiration what FiO2 is given with 2 L NC? 8 L facemask? 28%, 60% what are BiPAP settings to start a patient on (EPAP, IPAP, Vt, backup rate), at what IPAP do you worry about gastric distention? 5, 10, 6-8 mL/kg, 6 IPAP > 20 what are the 4 indications for invasive ventillation? failure to oxygenate, failure to ventilate, failure to protect, projected clinical course what are teh ABCD of teh vent cycle? A: triggering (initiation of inspiration) B: end of inspiratory flow C: cycling (start of expiratory flow) what is assist-control ventilation? VT is guaranteed at present flow rate with a minimum RR however pt can initiate breaths and trigger teh vent, so Pt can breath at higher RR if he wants can be either volume cycled or time cycled (pressure assist), volume is much more common what is PSV? SPV provides a preset level of inspiratory pressure with each vent detected pt effort best for spontaneously breathign pt to offer increased comfort what is SIMV? synchronized intermittent manditory ventilation, breaths may be triggered by the pt or time delapsed, vent will synch to pt breaths, if no breath is detected vent will deliver preset VT at preset time PSV is usually paired with what other vent mode for pt comfort and decrease in pt's WOB? SIMV volume assist control waveforms? 22 | P a g e pressure assist control ventilation waveforms? review advantages/disadvantages to different vent modes on p 77 do it after you intubate what is the first mode used? AC, usally volume controlled what are best initial vent settings? (VT, FiO2, RR)? what is normal minute ventilation? VT = 4-8 mL/kg; closer to 8 for COPD, closer to 4 for ARDS 7-8 L/min 92-94% what is peak airway pressure? inspiratory plateau pressure? which one corresponds more to barotrauma? how can you decrease Pplat? Ppeak = a measure of airway resistance; < 40 is ideal Pplateau = measure of compliance and alveolar distension, a static measurement; need an inspiratory hold of 1 sec; normal < 30 cm H2O Pplat decrease PEEP, decrease VT if you can't get FiO2 < 60 what should you do? increase PEEP waht is auto PEEP? how can tell its happening on tracing? badness, happens when expiratory time is too short to allow full exhalation. can decrease CO, need to adjust vent. To get rid of increase peak flow and decrease RR 25 | P a g e Assist-control ventilation Either volume or time cycled breaths given Usually the go to when you just started someone on the vent Gives the pt a set tidal volume and preset flow rate respiratory rate. Very rigid. However, if the patient wants to take extra breaths if they trigger them. Pressure support ventilation Waits for patient to start breath, and then helps out with a set amount of pressure Synchronized intermittent mandatory ventilation SIMV Delivers volume or time cycled breaths at a mandatory rate Patient can breathe spontaneously between mandatory breaths Spontaneous breaths count - this allows the patient to contribute to the mandatory tidal volume the machine requires them to breathe When do you give tPA in ACS? ONLY for a STEMI, and ONLY when PCI isn't readily available Tx of an inferior MI NO nitroglycerin Give fluids instead ABG findings in PE Decreased CO2 (hyperventilating) Decreased O2 (V/Q mismatch) When to give tPA in PE Only for huge ones and heparin's not working Lovenox class LMWH Airway in hematemesis pt Electively intubate it Tx of HTN urgency vs emergency No drip vs drip Intraabdominal HTN (criteria, effects) >12 mmHg End organ damage and decreased preload to heart causing hypotension 26 | P a g e CPP goal in TBI (and how to calculate it) 50-70 MAP - ICP SAH tx nimodipine to stop vasospasm and control BP Sepsis vs severe sepsis vs septic shock You know vs End organ damage vs Resistant to tx CAP tx beta-lactam and macrolide OR fluoroquinolone HCAP tx vanc/zosyn CAP immunocompromised pt (tx) Bactrim Endocarditis bugs Strep viridans and other streps, staph SBP abx ceftriaxone flagyl Pregnancy pyelo tx ceftriaxone Necrotizing fasciitis tx vanc/zosyn clindamycin Neutropenic fever abx Think G-, so cefepime C diff abx 27 | P a g e Flagyl When hypothermia helps (disease) V fib 1st step in respiratory arrest while ON the vent Disconnect them from the vent SVT tx Adenosine Wide complex tachycardia tx Amiodarone GI change in pregnancy LES tone decreases, increasing the risk of aspiration Preeclampsia 20+weeks, HTN, proteinuria/edema HELLP vs preeclampsia tx Delivery vs Mg Peripartum cardiomyopathy late in gestation incurable presents like CHF ACE-I in pregnancy NO What pulse oximetry value is considered hypoxic? <88%; 92%+ is ideal Most common cause of hypxemia V/Q mismatch Shunt = Congested air flow Dead Space = Imparied blood flow A-a Gradient goals 30 | P a g e Decrease the PEEP, even though it will decrease PaO2. (Note: you can't decrease the VT because it is already on the low end). A young asthmatic pt is on the vent. His lungs are very tight. He is on the AC setting and there is a lot of auto-PEEP. You correct it by reducing the rate, giving him more time to exhale and making sure he has enough flow. FiO2 is at .50. He is sedated and seems comfortable. On ABG the pH is 7.24, CO2 is 65, O2 is 80, and bicarb is 29. What would you do with the vent settings in this case? Keep the settings where they are. You can't hyperventilate the pt to blow off CO2 b/c the asthma will worsen. As long as the pH is > 7.2, the settings are okay as they are. CO2 will correct over time. Which two conditions are the most indicated for BiPAP? COPD exacerbation Cardiogenic pulmonary edema A 70 y/o pt with CHF presents with SOB, accessory muscle use, RR 34, SpO2 90% on 8L O2. CXR reveals infiltrates in a bat wing pattern. She also has LE edema. She is dx with a CHF exacerbation w/ respiratory failure. Her ABG shows pH 7.3, PO2 64, CO2 50. What is the best tx for this pt? Non-invasive BiPAP. A pt comes in w/ a femur fx and a rod is placed. Post-op he develops dyspnea and fever. HR 140, RR 30, SpO2 92% on non-rebreather. He is transferred to the ICU where you intubate, place a central line, and start resuscitating him. Hb 8.2, lactate 3.2, SVO2 is 52%. Why is his SVO2 low? How can we improve it? Decreased O2 delivery and increased consumption. (normal is 65-70) Administer packed RBCs - 1U of blood will change his Hb from 8.2 to 9.2. O2, fluid, and VT would not work. A young pt after an MVA comes to the ER hypotensive and tachycardic. CXR is clear. He has a contusion on his chest wall and torso. He is unconscious. What will give you the best insight on what is causing his shock? Hb 31 | P a g e SCV Urine Output FAST exam FAST exam 41 y/o pt in the SICU following debridement of b/l lower extremities for necrotizing fasciitis is intubated on AC. Temp 102, HR 116, RR 16, BP 92/46. ABG shows pH 7.23, PO2 133, PCO2 38, Na 139, K 3.7, Cl 102, Bicarb 16, lactate 4. Dx is metabolic acidosis w/ anion gap d/t infection. What is the most appropriate intervention? Increase VT Continue resuscitation Decrease RR Administer bicarb Continue resuscitation. Don't need to increase VT bc the pt doesn't have respiratory acidosis. If you decrease the RR, the pt will go into respiratory acidosis. A pt has obstructive uropathy. A catheter is placed d/t the obstructive kidney injury. After the cath is placed, he has massive diuresis to the point where he is hypotensive, tachy, and lactate is 2x the ULN from decreased perfusion. How would you correct this? Fluids - LR When treating hyponatremia, what is the first thing to assess? When do you give 3% NaCl? How do you correct it? 1. fluid status 2. seizures or changes in mental status 3. slowly, 8-12 meq over 24 hr What are the classifications of hemorrhagic shock? I: <15%; HR <100, BP normal, RR normal II: 15-30%; HR >100, BP normal, RR 20-30 III: 30-40%; HR >120, BP low, RR 30-40 IV: >40%; HR >140, BP low, RR >40 An 84 y/o pt fell down the stairs. He is moaning and crying. He has a C-collar in place. His neck is painful and he has bruising on his face. He is tachy but BP is okay. You administer 2L O2 bc SpO2 was 92%. Shortly after he deteriorates, becoming altered and then comatose. His left pupil > the right. He is herniating from cerebral edema. 32 | P a g e How do you treat him? Intubate and ventilate, maintaining c-spine precautions. Administer mannitol. A pt comes in with several cardiovascular RFs: elderly, DM, and HTN. He is having chest pain, SOB, and is diaphoretic. What diagnosis do you need to re-perfuse him immediately? STEMI What is the most appropriate management for both STEMI and non-STEMI? nitro if bp >80 morphine q 30 min bb oxygen if sats are <94% Oxygen Which NSTEMI needs to be sent to the cath lab immediately? NSTEMI w/ shock Which medication improves outcomes for pts with STEMI? ACE-I Give if BP is stable. It decreases LV remodeling and decreases afterload. A 70 y/o pt has been hospitalized for 15 days. He had a cholecystectomy and abscess formation which was tx appropriately. He has a central line in the right IJ. The site looks visibly infected, and he has a fever, is tachy, and hypotensive. WBCs are high. Blood culture and initial gram stain reveals G(+) cocci. What is the dx? What is the MC pathogen? What is the tx? 1. line-related infection 2. coag (-) staph epidermis 3. vanco + zosyn + ceftriaxone if MRSA: vanco + ceftriaxone if MSSA: zosyn + ceftriaxone What is the tx for meningitis? young pt: ceftriaxone + vanco > 50 pt: add ampicillin A chemotherapy pt becomes septic. You suspect a neutropenic fever. What is the tx? 35 | P a g e waht is the mnemonic for airway prep? SOAP-ME Suction Oxygen Airways (OPA, NPA, Ett) Position: adjust bed Monitoring and Medications: EtCO2, RSI drugs Equipment: DL, VL, bougie what are indicators of a difficult mask? beard,no teeth, OSA, high BMI, age > 55 how should you evaluate a patient for intubatioN? *same order you go through to acutally intubate: 1. neck mobility 2. external face: small mandible, surg scarring 3. mouth (<3 finger breaths of opening is worrying) 4. tongue/pharynx 5. jaw: thyromental distance (from anterior prominence of thyroid cartilage to tip of mandible what are the 2 NM blockers to know for intubation? sux, roc drugs: -lido p 28 a what periintubation drug has been shown to blunt response of increasing ICP in someone whith a head injury? lidocaine (1-1.5 mg/kg) what is goal temp ranges for targeted temperature management? what are the 2 potential big SEs? 32 to 36 C for at least 24 hours in comatose (GCS<8) patients following ROSC SEs: coagulopathy, increased risk of infxn what percentage of normal CO does chest compressions produce? 1/3 what is the goal CO2 following arrest? 38-42 (normocapnea) 36 | P a g e what are teh 3 broad types of respiratory failure? PNA is most often associated with which one? drug OD? CHF? COPD? dead space ventillation? hypoxemic (PaO2 <60), hypercapneic (PaCO2 >50), mixed hypoxemic (although can be mixed) hypercapneic hypoxemic mixed hypercapneic define shunt physiology? waht is at the other end of the VQ spectrum? no V, still adequate Q dead space what ratio is most useful in tracking hypoxia over time? P:F ratio, PaO2 and FiO2 normal is 300-500 define minute ventilation (VA) VA = RR* (VT - VD) VD = dead space define paradoxical breathing? why does it occur diaphragm is flaccid b/c of fatigue and moves upward during inspiration what FiO2 is given with 2 L NC? 8 L facemask? 28%, 60% what are BiPAP settings to start a patient on (EPAP, IPAP, Vt, backup rate), at what IPAP do you worry about gastric distention? 5, 10, 6-8 mL/kg, 6 IPAP > 20 what are the 4 indications for invasive ventillation? failure to oxygenate, failure to ventilate, failure to protect, projected clinical course what are teh ABCD of teh vent cycle? A: triggering (initiation of inspiration) B: end of inspiratory flow C: cycling (start of expiratory flow) 37 | P a g e what is assist-control ventilation? VT is guaranteed at present flow rate with a minimum RR however pt can initiate breaths and trigger teh vent, so Pt can breath at higher RR if he wants can be either volume cycled or time cycled (pressure assist), volume is much more common what is PSV? SPV provides a preset level of inspiratory pressure with each vent detected pt effort best for spontaneously breathign pt to offer increased comfort what is SIMV? synchronized intermittent manditory ventilation, breaths may be triggered by the pt or time delapsed, vent will synch to pt breaths, if no breath is detected vent will deliver preset VT at preset time PSV is usually paired with what other vent mode for pt comfort and decrease in pt's WOB? SIMV volume assist control waveforms? pressure assist control ventilation waveforms? review advantages/disadvantages to different vent modes on p 77 do it after you intubate what is the first mode used? AC, usally volume controlled what are best initial vent settings? (VT, FiO2, RR)? what is normal minute ventilation? VT = 4-8 mL/kg; closer to 8 for COPD, closer to 4 for ARDS 7-8 L/min 40 | P a g e If things aren't really improving in a matter of hours If your therapeutic goals haven't been met in 4-6 hours Manual decompression (when you use it) If patient is air trapping like crazy on the vent, and you disconnect it and push up on the patients diaphragm to get everything out What a high A-a gradient means V/Q mismatch Volume assist-control breath (Volume cycled) Vent delivers preset tidal volume Pressure assist-control breath (time cycled) Vent delivers a constant pressure over a preset time Pressure support breath (flow cycled) Same as pressure assist-control breaths, but the vent cuts out when the flow rate decreases to 25% of initial peak flow rate Assist-control ventilation Either volume or time cycled breaths given Usually the go to when you just started someone on the vent Gives the pt a set tidal volume and preset flow rate respiratory rate. Very rigid. However, if the patient wants to take extra breaths if they trigger them. Pressure support ventilation Waits for patient to start breath, and then helps out with a set amount of pressure Synchronized intermittent mandatory ventilation SIMV Delivers volume or time cycled breaths at a mandatory rate Patient can breathe spontaneously between mandatory breaths Spontaneous breaths count - this allows the patient to contribute to the mandatory tidal volume the machine requires them to breathe When do you give tPA in ACS? ONLY for a STEMI, and ONLY when PCI isn't readily available Tx of an inferior MI NO nitroglycerin Give fluids instead ABG findings in PE 41 | P a g e Decreased CO2 (hyperventilating) Decreased O2 (V/Q mismatch) When to give tPA in PE Only for huge ones and heparin's not working Lovenox class LMWH Airway in hematemesis pt Electively intubate it Tx of HTN urgency vs emergency No drip vs drip Intraabdominal HTN (criteria, effects) >12 mmHg End organ damage and decreased preload to heart causing hypotension CPP goal in TBI (and how to calculate it) 50-70 MAP - ICP SAH tx nimodipine to stop vasospasm and control BP Sepsis vs severe sepsis vs septic shock You know vs End organ damage vs Resistant to tx CAP tx beta-lactam and macrolide OR fluoroquinolone HCAP tx vanc/zosyn CAP immunocompromised pt (tx) Bactrim 42 | P a g e Endocarditis bugs Strep viridans and other streps, staph SBP abx ceftriaxone flagyl Pregnancy pyelo tx ceftriaxone Necrotizing fasciitis tx vanc/zosyn clindamycin Neutropenic fever abx Think G-, so cefepime C diff abx Flagyl When hypothermia helps (disease) V fib 1st step in respiratory arrest while ON the vent Disconnect them from the vent SVT tx Adenosine Wide complex tachycardia tx Amiodarone GI change in pregnancy LES tone decreases, increasing the risk of aspiration Preeclampsia 20+weeks, HTN, proteinuria/edema HELLP vs preeclampsia tx Delivery vs Mg 45 | P a g e may cause muscle fasciculations d/t depolarization of skeletal muscle and emesis can occur if abdominal muscle fasciculations are severe; can precipitate malignant hyperthermia Name 3 contraindications with succinylcholine ocular injury; head injury; hyperkalemia (potassium release of 0.5-1mmol/L will routinely occur, and massive potassium release can occur with burn or crush injuries) dosing of vecuronium 0.1-0.3mg/kg IV bolus dosing of rocuronium 0.6-1mg/kg IV bolus Name 1 benefit and 2 cautions with vecuronium and rocuronium benefit: no fasciculations because these are nondepolarizing agents cautions: slower onset of muscle paralysis and significantly longer duration than with succinylcholine drugs that can contribute to respiratory failure opioids, bzds, propofol, barbiturates, general anesthetics (midazolam, etomidate, ketamine), neuromuscular blocking agents (succinylcholine, vecuronium, rocuronium), aminoglycosides (gentamicin, tobramycin) mechanism of beta2 agonists stimulation of beta2 adrenergic receptors --> bronchial and vascular smooth muscle relaxation Name 2 beta2 agonists used in ARF albuterol (Proventil,Ventolin), levalbuterol (Xopenex) albuterol dosing 0.5% solution - 2.5-5mg q 2-4 hours per nebulizer **can start with 3 treatments spaced 20 minutes apart with further therapy adjusted based on response 90mcg/puff MDI - 1-2 puffs q 2-4 hours levalbuterol dosing 0.31, 0.63, or 1.25mg/unit dose solution - 0.63-1.25mg q 6-8 hours 45mcg/puff MDI - 1-2 puffs q 4-6 hours mechanism of anticholinergic agents competes with acetylcholine at the bronchial receptor site, resulting in bronchial smooth muscle relaxation 46 | P a g e Name 1 anticholinergic agent used in ARF ipratropium; delayed onset when compared to beta2 agonists and has more consistent bronchodilatory effects in COPD than in asthma Name 2 benefits of corticosteroids in ARF reduction in inflammation and decreased beta receptor tachyphylaxis dosing corticosteroids in ARF limited consensus exists; doses of methylprednisolone of 80mg/24 hours have been as effective as >360mg/24 hours; some clinicians begin with 1mg/kg/24 hours with adjustments as patient response dictates; IV and PO routes are equally as effective inhaled corticosteroids place in therapy after acute exacerbation, inhaled corticosteroids can be helpful adjuncts and may allow reduction in systemic steroid use; NOT recommended in acute severe bronchospasm Name 2 bronchorrheic agents (expectorant) saturated solution of potassium iodide (SSKI), glycerol guaiacolate (guaifenesin) Name an alkalinizing agent aerosolized sodium bicarbonate Name 2 mucolytics acetylcysteine, dornase alfa (Pulmozyme) Patient info: acetylcysteine has a disagreeable (rotten egg) odor; increases the volume of respiratory secretions and effective coughing is necessary to clear them; med may turn a light purple color after opening the bottle (this is normal); call doctor if symptoms of allergy develop Patient info: dornase alfa dornase alfa (Pulmozyme) - used in CF; keep refrigerated and discard if solution becomes cloudy/discolored; once opened entire contents of ampule must be used or discarded (no preservative) What is the initial therapy for most forms of shock? fluid replacement Name 2 types of solutions that can be used to replenish intravascular volume in the patient who is not anemic. crystalloids and colloids Name 2 advantages of crystalloids over colloids. 47 | P a g e 1) less expensive 2) accomplish the same goal as colloid What 2 crystalloid solutions are used for volume resuscitation? What is the initial bolus dose range? normal saline and lactated ringers; 500-1000 ml iv bolus initially and repeated as needed Why are D5W and 1/2NS not appropriate for volume expansion? they are quickly distributed throughout body fluid compartments and so do not offer any expansion of intravascular volume Name 3 colloid solutions for volume expansion. What is the initial bolus dose range? hetastarch, albumin, gelatins; 300-500 ml iv bolus initially and repeated as needed What is the indication for packed red blood cells? to increase oxygen carrying capacity in a patient with significant bleeding or anemia What is the indication for fresh frozen plasma? correction of a coagulopathy What is the first target endpoint in fluid resuscitation? The second? 1) correction of hypotension 2) decreased heart rate and correction of hypoperfusion abnormalities What happens if fluid resuscitation is overly aggressive? deterioration of oxygenation d/t increase in pulmonary capillary pressure and resultant pulmonary edema Name 5 vasoactive agents used in shock treatment. 1) dopamine 2) norepinephrine 3) epinephrine 4) vasopressin 5) dobutamine Define inotropic effect. alters the strength of the contraction of heart muscle Define vasopressor effect. causes vasoconstriction and elevates mean arterial pressure (MAP) Define chronotropic effect. alters the heart rate Dopamine (low infusion rate) 50 | P a g e -remember that measurements of input and output are not very helpful b/c they don't account for movement on fluid into the extravascular space What 2 vasopressors are recommended 1st line in septic shock if the patient remains hypotensive after volume replacement? 2nd line? -dopamine or norepinephrine -epinephrine or low dose vasopressin When is dobutamine used in septic shock? patients with adequate blood pressure and ventricular preload, but with hypoperfusion and low cardiac output If initial MAP<65 mmHg in septic shock ---> initiate vasopressor therapy until fluid resuscitation is optimized What can be considered in a patient with septic shock whose BP is poorly responsive to fluid and vasopressors? corticosteroids (hydrocortisone 200-300mg in 24 hours administered in boluses or continuous IV infusion) What is the primary goal in treating cardiogenic shock? -improvement of myocardial function -promptly treat arrhythmias -reperfuse with percutaneous intervention if myocardial infarction What agent can be used in cardiogenic shock when BP is reduced? Why? -norepinephrine (for severely hypotensive SBP<70mmHg) -dopamine (SBP 70-90mmHg) -they have both inotropic and vasopressor effects How do reduction in preload and afterload help in cardiac failure? improve hypoxemia (avoid when hypotension is present) How is preload reduction accomplished? -loop diuretics (furosemide and bumetanide) -venodilators (nitroglycerin and morphine) How is afterload reductin accomplished? arterial vasodilators (ACE-Inhibitors or occasionally nitroprusside) If a patient remains oliguric after an adequate fluid challenge, how can a nonoliguric state be induced? 51 | P a g e high dose loop diuretic (ie, furosemide 200mg slow IV push) *conversion to nonoliguric state may not change outcome, but fluid management is usually easier and dialysis may be avoided Low dose dopamine can be used to treat oliguric patients. True or False? False; low dose dopamine may increase urine output, but not recommended to use it for this purpose b/c it doesn't prevent renal dysfunction or improve outcomes When/how should fluids be restricted in renal failure? -when oliguric acute renal failure is confirmed -fluids should be restricted to the replacement of ongoing losses (including insensible losses) -some disease states are associated w/ substantial ongoing loss of intravascular volume (sepsis, pancreatitis, large open wounds)---> fluids req'd to maintain left ventricular preload hypokalemia etiologies -diuretic use (e.g. lasix, HCTZ) -vomitting (&/or NG tube suction) -profuse sweating -malnutrition, alcoholism -alkalosis -hypomagnesemia -hyperaldosteronism -insulin -beta-agonists (& other B-adranergic agents; e.g. epinephrine) -hyperventilation hypokalemia ECG findings -U waves -flattened or inverted T waves -wide PR interval -ST depression treatment of hypokalemia K </ 2.5: -life treatening sxs --> IV KCl 20-30 mmol/hr via central catheter -non-lifethreatening or no sxs --> enteral KCl 20-40 mmol q2-4 &/or IV KCl 10 mmol/hr 2.5 < K < 3.5: -enteral KCl 20-40 mmol q2-4 hyperkalemia etiologies -renal dysfunction -acidosis -K+ sparing diuretics (e.g. ENaC blockers [amiloride], aldosterone antagonists [spironolactone]) 52 | P a g e -ACE-i, ARBs -NSAIDs -hypoaldosteronism -cell death (e.g. tumor lysis syndrome, rhabdomyolysis, burns, hemolysis) -excessive K+ intake treatment of hyperkalemia -IV CaCl for ECG abnormalities (1st tx) -redistribute K+ (e.g. insulin [w/ glucose], NaHCO3, inhaled B2-agonists) -remove K+ (e.g. loop diuretic [in euvolemic/hypervolemic pts], sodium polystyrene sulfonate [binding agent], dialysis) Hyponatremia presentation -confusion -lethargy hyperosmolar hyponatremia etiology (Na+ <135) hyperosmolar state? (e.g. elevated glucose, mannitol tx) elevated lipids, proteins?: -consider hyperosmolar hyponatremia (elevated glucose) -pseudohyponatremia (artifact 2/2 elevated lipids &/or proteins) hypovolemic hyponatremia workup Uosm>300, Una<20, FENa<1%: -vomitting -diarrhea -third-space fluid loss Uosm>300, Una>20, FENa>1%: -diuretics -aldosterone deficiency -renal tubular dysfxn hypervolemic hyponatremia workup Uosm>300, Una<10-20, FENa<1%: -CHF -Renal failure (w/ or w/out nephrosis) -cirrhosis euvolemic hyponatremia workup Uosm<100, Una>30: -polydispsia Uosm>100 (usually >300), Una>30: -SIADH 55 | P a g e -regular insulin infusion (0.1 U/kg/hr) Electrolytes: -add K+ once <5 -if K+ < 3.3, hold insulin & replete K+ How do you diagnose airway obstruction? FEV1/FVC <70% Once airway obstruction is diagnosed, how do you determine whether it is d/t asthma or COPD? Give pt bronchodilator. if >12% improvement of FEV1 then asthma The Global initiate for Chronic Obstructive Lung Disease (GOLD) categorizes airflow limitation into how many stages? 4 stages of COPD GOLD 1 spirometric findings mild: FEV1/FVC = <70% FEV1 >80% predicted GOLD 2 spirometric findings moderate: FEV1/FVC = <70% FEV1 between 50% & 80% predicted GOLD 3 spirometric findings severe: FEV1/FVC = <70% FEV1 between 30% and 50% predicted GOLD 4 spirometric findings very severe: FEV1/FVC = <70% FEV1 <30% predicted How do you diagnose airway obstruction? TLC (total lung capacity) <80% Dx of airway restriction is dependent on 56 | P a g e ht, wt, race can be d/t intrathoraic and extrathoracic causes Intrathoracic causes of airway restriction pulmonary fibrosis, asbestos, interstitial lung dz, sarcoidosis Extrathoracic causes of airway obstruction central obesity, scoliosis, phrenic nerve paralysis, GB, MG, MS During pregnancy what will decrease? Functional Residual Capacity - the amount of air left in lung after normal expiration Why is decreased FRC in preggers a problem? if you run into complications while intubating the pregger pt will crash quicker d/t less reserve in lungs How to ensure ET tube is placed properly? GS: capnography device. will change from purple to gold/yellow once pt exhales CO2 also: bilateral chest rise auscultation lungs/stomach CXR A child presents to the ER with sudden onset of SOB. CXR shows the hyperinflation of only one lung - what does this suggest? foreign body aspiration Pt is admitted to ICU after falling off roof. He has a frontal lobe contusion and has a generalized seizure. How do you treat? IV benzodiazepines -> Lorazepam Why do you give IV benzodiazepines for generalized seizures and not phenytoin? benzos work IMMEDIATELY phenytoin is good to control recurrent seizures not immediate ones. it also takes 20 mins to work Hx & PE of aortic dissection central, crushing chest pain radiating to the back unequal pulsess in upper and lower extremities aortic regurg murmur different BP in each arm (usually hypertensive) 57 | P a g e Best imaging to confirm diagnosis of Aortic dissection? CT #1 priority when treating aortic dissection? lower HR Treatment of aortic dissection depending on type Type A: Emergency Type B: Non-emergancy. Meds: IV BB Labetolol lower HR & BP avoid drugs that give reflex tachycardia (when BP lowers and sympathetic NS compensates) What is contraindicated in. aortic dissection? No ACEi, CCBs, nitroglycerine, nitroprusside If a patient ingested drugs (OD) >4 hours ago and now presents to the ED what can you do for them? nothing best study to r/o PE CTA: computed tomography angiography How do you treat DKA? IV fluids - 1st IV insulin potassium supplementation regulate electrolytes Give glucose when BS is <250 How do you know when someone is no longer in DKA? when anion gap is normal <12 then you add long acting insulin turn off IV insulin drip MUST add long acting insulin BEFORE d/c of drip Pt presents with PNA, sepsis & shock. How do you treat? 1) 30 mL/kg (bolus) IV crystalloid bolus then 150mL/hour 2) IV vasopressors if still low give NE 3) steroids if refractory hypotension 60 | P a g e First step in txt pt with elevated ICP? elevate HOB Pt with stroke. neg CT for hemorrhage. What is the window for tPA? 4.5 hours Pt with HF on diuretics. Na 110 (hyponatremia) and seizures how do you treat? 3% NaCl Hypertonic solution 100 bolus 3% only given when seizures are present How fast can you correct hyponatremia? What is the AE if done too quickly? 8meq/24 hours central pontine myelysis PT has obstructive uropathy, catheter, massive amounts of urine output. Pt now is hypotensive how do we treat? IV fluids Pt presents in massive trauma & shock. Best diagnostic test? FAST exam -> US ScVO2 is low. (norm 65-70) How can we treat this? blood can help What is permissive hypercapnia? Aware of hypercapnia but allowing it anyway Pt on vent is septic. ABG 7.23 pCO2 Na 129 Cl 102 Bicarb 16 K 3.9 what is anion gap? AG = 129 - (102 + 16) Metabolic: do not touch vent Focus on management with fluids & abx Low SVO2 is d/t either 61 | P a g e not getting enough or consuming too much - decreased delivery - increased consumption Pt with HF and O2 sat 90% on 8L via O2 mask. Lower extremities edema, crackles on auscultation, tachypnea. In addition to diuretics what else can you do for O2? CPAP or ByPAP (noninvasive) intubate ONLY if in shock What does the Peak airway pressure alarm signify? retaining of CO2 air building up in lungs -> airway pressure increases -> breath stacking -> auto PEEP how do you treat AUTO peep? d/c vent press on pts chest to let air out ( decrease P = increase VR) sedate patient ( decrease RR , low TV) decrease rate & acceleration permissive hypercapnia (CO2 will come down on its own) ARDS & hypoxic pt. How do you treat? place on vent then either: 100% O2 increase PEEP Pt on vent with COPD exacerbation, suddenly crashes, PEEP pressure high, plateu high. No breath sounds on one side. and trachea deviation. What does this pt have? Dx: PTX Txt: needle decompression What type of respiratory failure happens with OD? hypercapnic Classical example of shunt as a cause for V/Q mismatch? anything that causes dz in alveoli PNA atelectasis alveoli filled with anything other than air -> blood, pus, fluid 62 | P a g e Pt has cardiac arrest, CPT, unresponsive. What do you do? target temperature management. (cool to 33-36 C) leave cool for 24 hours rewarm by .25 degrees every hour cool people w/ IV femoral catheter OR pads on body If you cannot intubate pt d/t difficult airway use laryngeal mask airway Hyperkalemia pt who needs to be intubated. What drug do you NEVER use? Succinylcholine can worsen hyper K what drug blunts the vagal response during intubation? Lidocaine How do you estimate the difficulty of intubation? use thyromental distance= less than 3 fingers (6 cm) from Adam's apple will be a difficult airway larynx is anterior <6 What is pulses paradoxus? decrease in BP > 10 mmHg with inspiration * normal decrease of 2-4 mmHg with inspiration. When physiology is exaggerated we call it pulsus paradoxes * negative pressure on inspiration to draw air in * increase VR Most reliable sign in a critically ill patient? tachypnea Most important indicator that a patient has a severe illness? Tachypnea 3 respiratory types, and their criteria Hypoxemic (PaO2 <50-60) Hypercapnic (PaCO2 >50, pH <7.36) Mixed 65 | P a g e Synchronized intermittent mandatory ventilation SIMV Delivers volume or time cycled breaths at a mandatory rate Patient can breathe spontaneously between mandatory breaths Spontaneous breaths count - this allows the patient to contribute to the mandatory tidal volume the machine requires them to breathe When do you give tPA in ACS? ONLY for a STEMI, and ONLY when PCI isn't readily available Tx of an inferior MI NO nitroglycerin Give fluids instead ABG findings in PE Decreased CO2 (hyperventilating) Decreased O2 (V/Q mismatch) When to give tPA in PE Only for huge ones and heparin's not working Lovenox class LMWH Airway in hematemesis pt Electively intubate it Tx of HTN urgency vs emergency No drip vs drip Intraabdominal HTN (criteria, effects) >12 mmHg End organ damage and decreased preload to heart causing hypotension CPP goal in TBI (and how to calculate it) 50-70 MAP - ICP SAH tx nimodipine to stop vasospasm and control BP Sepsis vs severe sepsis vs septic shock 66 | P a g e You know vs End organ damage vs Resistant to tx CAP tx beta-lactam and macrolide OR fluoroquinolone HCAP tx vanc/zosyn CAP immunocompromised pt (tx) Bactrim (TMP-SMX) Endocarditis bugs Strep viridans and other streps, staph SBP abx ceftriaxone flagyl Pregnancy pyelo tx ceftriaxone Necrotizing fasciitis tx vanc/zosyn clindamycin Neutropenic fever abx Think G-, so cefepime C diff abx Flagyl When hypothermia helps (disease) V fib 1st step in respiratory arrest while ON the vent Disconnect them from the vent SVT tx 67 | P a g e Adenosine Wide complex tachycardia tx Amiodarone GI change in pregnancy LES tone decreases, increasing the risk of aspiration Preeclampsia 20+weeks, HTN, proteinuria/edema HELLP vs preeclampsia tx Delivery vs Mg Peripartum cardiomyopathy late in gestation incurable presents like CHF ACE-I in pregnancy NO NEW NEW