Week 2 Critical Care

8/11/2019 Week 2 Critical Care

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CRITICAL CARE Bold = Question stem;Normal font = Annas notes from Dr. Esterl;

Blue font = Beckys notes from Dr. Nguyen

Common causes of post-op fevers:

5 Ws: Water (UTI), wound infections (intra-abdominal, post-op abscess), Wind (atalectisis, pneumonia), Walking, Wonder

drugs; also sinusitis, Top 3 nosocomial infectionpneumonia, UTI, line infections.

How to prevent pneumonia (biggest risk factor is being on the ventilator). Can do incentive spirometries. Elevate head of

bed, performing oral mouth care (chlorhexadine, suction), early extubation.

Over next 3-5 days think about UTI: risk factor is foley catheter, so get that out as soon as possible. Monitoring UOP andclosely, Epidural (urinary retention) or BPH patients need Foleys, but for most part need to get foley out.

Over 7 days can develop post op wound infectionlook at wound, look for foley, and peripheral IV spots, central line,

listen to lungs got phlegm or new respiratory sxs.

Over 7 daysfever and DVT development. Sx, obese, cancer, Virchows triad. Think prophylaxis, put on Lovenox. For

gastric bypass or morbid obesitystart lovenox prior to sx.

For line infectiontake it out. If they are on TPNtake out line and put in new one. Central line needs to come out and

cant be changed out. If positive cx and high fever, change line to new site and send tip for cultureneed 15 CFU to confirm

line as site of infection.

Wonder drugsusually ID on board by this point. ID typically stops all antibiotics as source of fever?

Prolonged ICU pt with persistent feversthink acalculous cholecystitis, perirectal abscess, or things people come into

hospital with (random body abscesses), sinusitis

A 72 year old male underwent an elective sigmoid resection for volvulus. Prior to the operation he received mechanical

bowel preparation. He received preoperative intravenous cephalothin 30 minutes before incision. After intubation he

received a double lumen central venous catheter, a radial arterial catheter, a nasogastric catheter and a urinary

catheter. On the seventh postoperative day the patient develops intolerance to food, confusion, shortness of breath and

abdominal distension. The vital signs are temp 103, P 120, RR 28 and BP 103/60. His O2sats are 89% on room air. He

is confused and diaphoretic. The double lumen central venous catheter is still in place. The arterial line was

discontinued on the second postoperative day and the urinary catheter on the fourth postoperative day. The heart has

tachycardia. The lungs have rhonchi bilaterally. The abdomen has distension, tenderness in the lower quadrants, with

decreased bowel sounds. The wound has slight erythema and induration. The rectal exam is slightly guaiac positive

and there is fullness in the pelvis. The patient does not have a history of diabetes but the serum glucose is 226 mg/dL.

?Potential sources of post-op fever in this patient: IV line, central venous catheter, abd distentionobstruction in bowel.

Rhonchi, blood cultures/CT scan for obstruction in bowel.

Do CXRr/o new infiltrate, get rid of central line and send tip for cx. Start broad-spectrum antibiotics. For the woundif

cellulitis, rising WBCs, fevers, open up wound and do dressing changes. Risk factor is colon sx. Even in elective setting hashigh risk of wound infection. Risk of post-op intraabdominal absecess. If has abscess measures 6x6 cm and If not

multiloculated or accessible, can do percutaneous U/S guided or CT guided drain, get catheter in place until not longer febrile.

Another risk factor is poorly controlled diabetes.

Causes of post-operative fever:

post-op day 1

- malignant hyperthermia(can occur w/in 24 hrs of operation)

tx: remove offending agent (get pt off of anesthetic agent, given Dantrolene sodium).

- atelectasis(low-grade fever to 101 at max). May also complain of nonproductive cough, see basilar atelectasis on CXR

tx: mobilize pt, spirometry to get pt to cough and take deep breath (pulmonary toilet)

- skin infection/ necrotizingfasciitis(fever up to 104) beta hemolytic group A strep, clostridium perfringens can be

in GI surgeries

tx: involve healthy skin w/ advancing erythema (surgical emergency), IV abx, penicillin, OR debridement.Necrotizing fasciitis is subcutaneous / Scarpas fascia. Remove skin until it bleeds. can occur at any day post-op, but usually

day of operation.

post-op days 3-5

- urinary tract infection(d/t catheter)do U/A to check for nitrite/nitrate positive, pH, leukoesterase positive, WBCs on

microscopy

tx: broad-spectrum abx and tailor to organism

- pnacomplain of fever, productive cough, diaphoresis, yellow, productive sputum. dx w/ CXR. may be lobar or

interstitial pna. get deep culture and G-stain. Look for WBCs and bact.

tx: broad-spectrum abx and tailor to identified organism


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post-op day 7

- DVT

- simple wound infxn, cellulitis

- abscessposs intra-abdominal, wound-infxn, central line.

redness, induration, no drainage, low-grade fever = cellulitis. do blood cultures.

tx: abx (oral or IV depending on severity)

red, indurated, warm, cloudy, yellowish drainage = abscessor simple wound infxn. dx w/ simple exam.

tx: open wound. pack with warm dressings. no cultures needed. make sure fascia is dehisced. dont need abx.

wound separation with bowel visible in base of wound = dehiscence(separation of fascia) w/ eviscerati on(bowelscome out) mortality due to cause of dehiscence. surgical emergency. salmon-colored fluid drainage (not purulent).

tx: IV abx, operate, debride edges of fascia, close edges.

central li ne inf xn- glu. do blood culture through central line and peripheral culture. if + pull catheter, remove

central line

(Q: diff btwn incarcerated hernia and dehiscence: hernia is a dehiscence (implies viscera and muscles are separated).

may be in tra-abdominal abcessdx w/ labs, CBC, WBC, hyperglycemic do obstructive series (upright to r/o free

air, supine film, lateral decubitus film). CT scan w/ IV, oral, and rectal contrast. if find mass

tx: percutaneous drainage (on boards, drain abcesses regardless of size). FAST exam would show fluid in pelvis

(may possibly see air in pelvis, but diff to differentiate from intra-luminal air)

- thyrotoxicosis, adrenalinsufficiency, lymphangitis

stress hormones cause hyper-glycemianeeds to be controlled w/ insulin drip b/c s risk for wound infxn.

pt is guaiac + d/t colostomy procedure itself

A 45 year old male falls 20 feet from a tall oak tree in his front yard as he attempts to rescue his cat. He sustains a

spiral fracture to his right femur for which he undergoes open reduction and internal fixation. Preoperatively the

patient receives intravenous cephalothin (Anceph) and intraoperatively he receives 2 units of packed red cells. On the

third postoperative day he begins to complain of significant shortness of breath. The vital signs are temperature 101.5,

P 105, RR 34 and BP 110/70. The patient appears uncomfortable, diaphoretic and tachypneic. The neck shows no

jugular venous distension. The heart has tachycardia but no gallops, rubs or clicks. The lungs show scattered rhonchi

bilaterally. An arterial blood gas on 40% FM (face mask) O2shows pH 7.47, PaO258, PaCO232, sat 87%. The chest

radiograph shows bilateral fluffy infiltrates.

Fat embolism syndrome, also consider ARDS

Assess ABCDEs:A: patent airway, tells you he developed SOB.

B: O2 sat 80% (not good)can give more O2. On face mask 40%increase FiO2 to 100% non-rebreather, any CO2 they

breath out they will replenish with O2 vs nasal cannula. If O2 sat still poor and tachypneicintubate. Ways to increase

O2more aggressive form, nasal cannulaface maskintubation. Acute process, both lungs involved. CXR with fluffy

infiltratesARDS. His risk factors: blood transfusion, trauma, sepsis. Another dz process that mimics ARDSfat embolism

(fall, femur fracture or long bone or pelvic fracture, bone marrow fat embolizes to lungs), can also have microembolis of fat

petechiae on skin. Diffuse bilateral infiltrate. Prophylaxistreat fracture early on rather than delayed internal reduction/open

fixation. Supportive txpulm, ARDS ventilation protocol. Intubate for better oxygenation. Normal tidal volume for setting

ventilator is Weight based: 5-8 cc/kg of tidal volume (for ARDS). Overdoing it can lead to barotrauma. For PCO2nl PCO2 is

40-45, PaO2 is 95. Adjust PCO2: If PCO2 50, can increase rate. If rate is 16, going up isnt going to be tolerable to patient.

Adjust minute ventilation = RR x TV for PCO2. For PaO2adjust FIO2, risk for prolonged FIO2 is oxygen radical damage,

but can increase PEEP (positive end expiratory pressure). Physiologic PEEP is 3-5. When set the vent, PEEP set at 5, RR tachypnea = resp alkalosis; hypoxic

- get full labs, CBC, chem., CXR, U/S of pts leg if uni -lateral edema (to r/o DVT)

> if pt has vomited and is SoB worry about aspiration pna. dx: blood gas, CXR, CBC. pna w/ aspiration in most

dependent parts of lung. Intubate.

tx aspiration: intubation, bronchoscopy!, remove all of particulate matter. do NOT put on broad abx prophylactically -

wait for signs of clear pna. if suspect aspiration, do bronchoscopy immediately (txs effectively 70% of time)


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> fat embolismSoB, petechiae on trunk, mental status changes, renal dysfxn, thrombocytopenic on labs.

tx: good supportive care. sxs improve by 3-4 days after embolic event. put on ventilator 3-4 days. stress of trauma

mobilizes fat, not just from long bone fx (although classically it is from fx)

> pnadiaphoresis, SoB. do CXR. Strep pna - MCC of CAP. Enterobacter, staph, klebciellaMCC of hosp-acquired pna in

SA (depends on hosp)

> rib fx w/ pulm contusionflail chestw/ mult rib fx. underlying pulm contusion hurts pt.tx: intubate and put on PEEP w/ good pain control.

> acute lung injury w/ ARDSpresentation hypoxic (PaO2 < 60, bilateral fluffy infiltrates on CXR, FiO2 (as decimal), ratio of

PAO2/FiO2 < 200, wedge press < 18 on Swan-Ganz catheter (> 18, elevated = congestive heart failure), loss of surfactant,

gradings across membranes, deposits of fibrin and WBCs, diffusion prob.

tx: ID and tx underlying cause (ex. intra-abdominal abscess)

> pulm edemaand cong heart failurehave elevated wedge pressure. hypotension, elevated RA pressures, central pressures

tx: diuretics

> atelectasis

> PEunilateral lower extremity edemaDVT causing pulm embolism. do D-dimer in hospitalized pts. do sonogram of pts

leg (will see thrombus in femoral or iliac vein), use probe to try to compress vein (cant compress in DVT)

for PEmay not see on CXR (usu nl), do blood gas (resp alkalosis b/c tachypnic), EKG w/ sinus tach, V/Q scan & pulm

angiogram (on tests)high-resolution CT scan (in real life) will only see big ones. V/Q scan usu shows ratio b/c of

perfusion and nl ventilation. gold standard = pulm angiogram for pulm embolism

tx: therapeutic heparin (1,000 units/hr), order PTT (60-80s) to follow, then switch to warfarin (monitor w/ INRgoal is 2-

3 s)

A 25 year old female is extubated after an uncomplicated 1 hour laparoscopic cholecystectomy. Ten minutes after her

arrival to the recovery room the patient becomes lethargic and nearly apneic. The vital signs are temp 99, P 100, RR 6,

BP 110/70, weight 72 kg. The recovery room nurse recognizes the problem immediately and calls a code blue. You

intubate the patient without difficulty and order a chest radiograph. The ventilatory settings are AC mode, rate 8/min,

TV800ml, FIO2 40%, PEEP 5 cm H2O, PS 5cm H2O (typical settings). You draw an arterial blood gas and the results

are: pH 7.20, PO2 180 mmHg, PCO2 56 mm Hg, HCO3 26 mEq/L (nl) and O2 sat 99%. What changes do you make forthe ventilator?

know how to make changes in respirator

probpt was too anesthetized. hypoxic b/c anesthesia still on board. get a blood gas!. pt has pure resp acidosis (b/c bicarb is

nl)

changes to make on ventilator to improve hypercarbia rate from 8 to 10 -12/min. draw another blood gas in 30 min. could

also tidal vol (but do rate 1st). tidal vol of 5-8 cc/kg

if blood gas showed hypoxia w/ nl PaCO2 FiO2 (but only for a couple days or prob w/ O2 toxicity, esp retinal). Usu

change FiO2, then change PEEP. PEEP

A 76 year old male undergoes an abdominal exploration for a ruptured infrarenal aortic aneurysm. Intraoperativelythe patient receives 0.9% NS 3 liters and PRBCs 4 units. Intraoperatively the patient receives a nasogastric catheter, a

pulmonary artery catheter, a radial artery catheter and a urinary catheter. The patient survives the operation and

recovers in the ICU on the ventilator in a critical state. The vital signs are temp 100, P 106, RR 16 and BP 110/60. Since

his arrival in the ICU 2 hours ago the urine output has been only 5 ml total.

How do u approach patient?

Worry about renal artery embolismstart with abdominal U/S?

Patient has a foley.

For renal failure, need methodical workup

Differential for low UOPvolume depletion (pre-renal azotemia, hypovolemia), Renal, Post-renal.


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Pre-renal-- UAget FENA, electrolytes, BUN/Cralways know baseline, >20 Prerenal. Give a 500 cc bolus of fluid

at bedside. Not uncommon for post-op patient to need additional fluids. If hypovolemia problem, if not responding to 500

cc, can give another 500 cc in next hour, or give 1 L at once, should see response right away. For FENANa and Cr,

2% think ATN. Reasons for hospitalized patient to have ATNantibiotics or contrast (from CT).

Contrast-induced nephropathy occurs within 72 hours.

Post-renalfoley issue (so nurses flush the foley). Renal U/Slook for hydronephrosis, obstruction at UV junction

Iatrogenic causes of renal failureVolume depleted, contrast study, nephrotoxic antibiotics. Flush the foley and make sure

not kinked off, give fluid volume. Find out recent UOPs and fluid rescuscitation given, send off labs to include urineelectrolytes.

Can have blood clot with renal transplant

A 45 year old alcoholic male who has been in the surgical intensive unit for 3 weeks due to complicated acute

pancreatitis returns from the operating room after debridement of infected necrotizing pancreatitis. Intraoperatively

the patient required 3 liters of 0.9% normal saline and 2 units of packed red cells. He returns to the intensive care unit

on the ventilator with vital signs temp 102, P 120, RR 16 and BP 110/60. The urine output for the 3 hour case is only 70

cc. The lungs have coarse scattered rhonchi. The heart has tachycardia but no gallops, rubs, murmurs or clicks. The

abdomen has distension, dullness to percussion with absent bowel sounds. The new midline incision has no signs of

inflammation. The patient has a triple lumen central venous catheter, a radial arterial catheter and a urinary catheter

in place. The patient has been on broad spectrum antibiotics with zosyn (piperacillin) and imipenem for the last 5 days

but still remains febrile. The patient has been on hyperalimentation though a dedicated port on the central venous

catheter for 2 weeks.

Review diff types of shock: septic shock, hypovolemic shock from bleeding/retroperitoneal fluid shift (3 rdspacing of fluid),

neurogenic shock, adrenal insufficiency

to work up pt: routine labs, full cultures blood, urine, sputum, ventilator.

tx: may broaden coverage of abx

> shock = oxygenation, inadequate tiss perfusion

> hypo-volemic shockMCC = hemorrhage. 2ndMCC = hemorrhage. can also have 3rdspace loss into retroperitoneum,

diarrhea, bad burn w/ insensible loss, polyuria

physical exam appearancetachycardic, cool, clammy extremities, diaphoretic. Swan-ganz catheterput into central

vein (use R jugular 1st). mult portspulm artery port, measure cariac output and index, balloon helps measure blood press,calculate resistance, wedge press. only use on critically ill pts.

arterial line appearancehypotensive

swan-ganz cathRA press low, PA press low, low CO. peripheral vascular tone, wedge press

tx: crystalloid fluids (lactated ringersdont use in pts w/ renal dysfxn, or nl saline use in pt w/ crush injury) given up-

front.

> traumatic shockup-regulated cytokine release (sub-set of hypo-volemic shock)cool, clammy skin.

tx: fluids

> septic shockphysical exam appearance early: confusion, warm, dry extremities. arterial line (art line) hypotensive,

RA press , PA press , wedge press , shunting peripherally (warm extremities), SVR CO (vasodilated).

tx w/ lots and lots of fluids

late septic shocklook like hypo-volemic shockcool, clammy, hypotensive

> neurogenic shockVSs: pulse bradycardic, BP, probs w/ symp tone w/ un-opposed vagal tone. warm, dry extremities.

flaccid reflexes, arterial line - BP, RA press , PA press , wedge , lowest poss SVR (no tone peripherally), CO (b/c SVR

is so low). lesion above C3-5 pts apneic. tx: lots of fluid upfront (liters and liters) may need vaso-dilator (pure alpha

agonist).

> hypo-adrenal shock* - esp in pts on low-maintainence steroids. dont respond appropriately to fluid therapy. hyper-

pigmented skin, tachycardic, bradycardic, hypotensive b/c loss symp tone, ejection fraction, tachypnec. labs: Na, K.

2 hemodynamic pictureshypovolemic or normovolumic

- do cortisol stimulation test, but tx w/ Dexamethasone up-front for tx (rule problem in, then give steroids tapered over a

couple of weeks).


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>cardiac compression shockhypotensive, tachycardic, JVD, heart tones, nl breath sounds. art-line: central pressures.

dx tamponade w/ pulsus paradoxus, U/S w/ fluid in pericardial space.

tx: pericardiocentesis directed towards L upper scapular border. know youre in pericardial space b/c VSs improve

(pericardial space blood doesnt clot well, but does from ventricles). Can also do U/S guidance. do pericardial window.

> cardiogenic shock: SoB, clammy extremities, bilateral rales, S3 murmur, pleural effusion, engorged liver, ascites, peripheral

edema. art linehypotensive. Swan-ganz: RA press, PA, wedge, slightly vasoconstricted on SVR, CO

tx: rate first (btwn 60-100). then tx rhythm. tx pre-load, then afterload. then heroic efforts - LV support, echmo,vasopressor support. (order imp!). give diuretics upfront.

*know physical exam findings and how to tx diff types of shock.

A 15 year old male sustains a severe motor vehicle injury. EMS performs orotracheal intubation with in line

neck stabilization in the field, places two large bore IV catheters, administers lactated ringers 1 liter

over 10 minutes and transfers the patient to the Emergency Room at UH. He is strapped to the back board

with a cervical collar in place. On examination his vital signs are temp 99, P 52, RR 25 and BP 75/55.

He is comatose. His left pupil is 2mm larger that the right pupil. The heart shows bradycardia but no

gallops, rubs or clicks. The lungs are clear. There is an obvious cervical spine injury. His abdomen is soft,

and slightly distended with minimal bowel sounds. There is no bulbocavernosus reflex. The upper and lower extremities

are flaccid. He has warm and dry upper and lower extremities.

Maintain neck and c-spine in place, get radiographs. Mass effect with left pupil.

ABCDEs

A:intubated

B: lungs clear

C: two IV catheters in place, give 2 L more of fluid and still had BP 80/60. Check for hemorrhage. FAST negative. Upper

and lower extremities w/no long bone fractures. CXR clear. 2L of packed RBCs. Give pressors because of neurogenic shock

Beta agonist dobutamine. Spinal cord injury--dontget tachycardic and hypotensiveneurogenic shock, no sympathetic

outflow so cant compensate for hypotension with increasing heart rate or contractility. Pt with neurogenic shock cant have

vascular constrictionEpi cant act on alpha receptors? Dopamine is good starting point, but if still hypotensive give alpha

agonist like phenylephrine. R/o hemorrhage as a source of hypotension. Severed spinal cord and neurologic injury.

D: Spinal cord injuryanti-inflam, give steroid like methylprednisolone or methylprednisone before first 8 hours after

injury. Bolus 30 mg/kg followed by continuous infusion.

A 45 year female undergoes an appendectomy for gangrenous appendicitis. She recovers on the surgical ward. She

received preoperative intravenous cefoxitin. She has been on prednisone at home for asthma for last 1 year period. On

the first postoperative night the nurse calls to state that the patient is febrile and hypotensive. The vital signs are temp

103, P 110, RR 18, and BP 104/60. The patient is slightly diaphoretic. The lungs are clear. The heart has tachycardia.

The abdomen is soft with slight distension and appropriate incisional tenderness. You order lactated ringers solution 1

liter fluid bolus but the patient remains hypotensive. The serum chemistry panel shows Na 120 mEq/L, K 5.2 mEq/L

and HCO3 29 mEq/L.

Causes of hypotension post opseptic shock (usually not day 1), fluid loss (hemorrhagic shock, post-op; start with bolus,

if worried about bleeding can get stat CBC which is fine in this patient).

Could also be cardiogenic shocksustained MI post sx, get cardiac enzymes (takes 4 hours, wont wait that long) and

EKG, do hx and exam. EKG normal.

PE suspectedgot dopplers of extremity if DVT, also spiral CT for PE.Could also be adrenal insufficiencysteroids; patient populations that could develop this are critically ill population in

ICU for a long time, give volume not responding. Start antibiotics which dont help, Echo to r/o cardiogenic shock but echo

fine. During illness adrenals cant keep up with demandin ICU order serum cortisol if


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RR 26 and BP110/70. There is an endotracheal tube in place. There is a double lumen central line in the right neck.

The heart has tachycardia but no muffled heart tones. The neck shows no jugular venous distension. The breath

sounds in the right chest are normal. The left thorax is dull to percussion with absent breath sounds.

You puncture the right internal jugular vein for placement of a single lumen catheter for hyperalimentation.

The patient becomes anxious and takes a deep breath. The patient then becomes agitated and suddenly

unresponsive. The vital signs are temp 99, P 126, RR 28 and BP 76/58. The neck shows jugular venousdistension. The trachea is in the midline. There is a loud cogwheel (machinery type) murmur.

The breath sounds are normal bilaterally. The patient then proceeds to asystole and you initiate

cardiopulmonary resuscitation immediately.

Complications of a central line: arrhythmia (from guide wire in atrium), infections, pneumothorax (


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~ GI hemorrhage ~

A 55 year old male with a long history of cigarette and alcohol abuse presents to the Emergency Room at the Veterans

Hospital with massive hematemesis. He states that his stomach became distended and he vomited bright red blood. He

describes mild nausea but no abdominal pain. His medications include aldactone, lasix and lactulose. His vital signs are

temp 98, P120, RR 26 and BP 110/60. He is pale and diaphoretic. The skin has jaundice with scattered spider

angiomas. The lungs are clear. The heart has tachycardia but no gallops, rubs or clicks. The abdomen has tense ascites

with shifting dullness. The liver is not palpable but the spleen is prominent. The rectal exam shows no masses but isstrongly guaiac positive. There are soft reducible umbilical and bilateral inguinal hernias. The chest has gynecomastia

and the testicles are atrophic. The lower extremities have mild peripheral edema.

dx: liver failure

pt: hypotensive, tachycardic, massive bleeding. tx like any other trauma pt will prob need intubate (2 large bore IV caths,

labs, amylase/lipase, CBC, INR, U/A, CXR, obstructive series, type/cross for blood)

diff: esophageal/variceal hemorrhage, Mallory-Weiss tear, nosebleed, esophagitis, esophageal cancer, gastric cancer, gastritis

from alcohol, duodenal tumor

imp questions: variceal vs. non, acute vs. chronic

8-10% mortality w/ GI hemorrhage

upper vs. lower GI hemorrhage differentiate by dropping a naso-gastric tube (bile = lower GI source). Upper endoscopy (1st

diagnostic test)diagnostic and therapeuticgo to 2ndportion of duodenum

tx variceal hemorrhage w/ banding

if cant find source of hemorrhage do bleeding scan (nuclear scan w/ tagged RBCs very sensitive to ID hemorrhage

shows + activity, but wont show source or organ that is hemorrhaging). + bleeding scan then do angiogram to help ID

branch w/ hemorrhage (tx: by embolizing bleeding branch).

A 50 year old female presents to the emergency room at University Hospital with a brief but massive episode of painless

hematochezia. She has never had an episode of hematochezia like this before. She denies fever, nausea, vomiting, or

abdominal pain. She has no family history of cancer. She has had no weight loss. She is on no medications. No other

family members are ill. She has not traveled outside the US. She has not eaten contaminated food. The vital signs

include temp 98, P106, RR 20 and BP 110/70. Her mucous membranes are dry and slightly pale. The abdomen is soft,

nondistended and nontender with no masses. There are decreased bowel sounds. The rectal examination shows no

masses but strongly guaiac positive.

diff: massive lower GI hemorrhage

tx: IV cath, intubate if needed, full lab, obstructive series

- start w/ good rectal exam, thorough anoscope exam (find blood is more proximal). then do endoscopyfull colonoscopy to

start. if tons of blood do bleeding scan (b/c radiologists wont do angiogram w/o + bleeding scan). bleeding scan for

hemorrhage, wont show which organ isbleeding (do angiogram). colon sensitive to ischemia. angiogram to ID source of

bleedingif pt is stable take to OR for partial resection.

common causes of painless lower GI hemorrhage in GI ptcancer, diverticular dz, AV malformations.

MCC of bleeding in ped ptmeckles, inflammatory bowel dz

painful bowelanal fissure, ischemic bowel, inflammatory bowel dz

aortic operationbleeding on post-op day 1 = sigmoid ischemia b/c IMA origin not implanted into graft do gentle endoscopy

to check for ischemia. Aortic enteric fistula 1 yr post-op. investigate aortic operation closer.

A 27 year old female with systemic lupus erythematosis has been referred for placement of a primary arteriovenous

access for hemodialysis. In your clinic she complains of mild shortness of breath, frequent nausea, decreased appetite

and moderate edema in the lower extremities. The vital signs are temp 99, P 110, RR 28, and BP 190/110. She has mild

jugular venous distension. The lungs have rales bilaterally. The heart has tachycardia with an S3 murmur and a

prominent pericardial rub. The abdomen shows a palpable, slightly tender liver 2 cm below the right costal margin

with small amounts of ascites. There is prominent 3+ pitting edema in the lower extremities. The CBC has Hct 25%,

WBC 6000/mm3 and plt 110, 000/m3. The serum chemistry shows Na 130mEq/l, K 6.7 mEq/l, Cl 109 mEq/l, HCO3 16

mEq/l and glucose 140mg/dl. An EKG shows tall peaked T waves.


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Manage the hyperkalemiaIV 1 amp calcium gluconate to stabilize the myocardium, can also give IV insulin 10 units and

1 amp D50 to move K intracellularly, kayexelate (slow)then recheck potassium. Albuterol works by dragging K

intracellularly by Na/K pump? If still hyperkalemicdo emergent dialysis.

Get EKGIf Widened QRS, peaked T waves, Depressed ST segmentsee if respond to Calcium gluconate and

insulin/glucose, call nephrology to get onboard for dialysis.

Other indications for emergent dialysisuremic (high BUN and mental status changes), fluid overload refractory to lasix,

acidosis, salicylate intoxication, electrolytes. Pneumonic: AEIOUs.

A 4 month old male presents to the Emergency Center at Christus Santa Rosa Hospital with continuous projectile non

bilious vomiting. The vital signs are temp 98, P 120, RR 16 and BP 78/60. The infant is listless. The heart has

tachycardia and scattered arrhythmias. The lungs are clear. The abdomen is soft and nontender with a prominent

gastric bubble in the left upper quadrant and a palpable olive in the right upper quadrant. The rectalexam is

negative. The serum chemistry shows K 2.8 mEq/L.

Pyloric stenosis, has hypochloremic, hypokalemic metabolic alkalosis. More urgent matter is fixing electrolyte

abnormalitygive rescusitation fluid and get alkalosis cleared.

***Lost the last 15 minutes of lecture***

A 66 year old male undergoes left lobectomy for adenocarcinoma of the lung, and he returns to the intensive care unit

on the ventilator. On the second postoperative day he develops bloody secretions from the endotracheal tube, bloody

drainage from the thoracotomy incision and bloody drainage around all intravenous catheter sites. The chest

radiograph reveals a probable right lower lobe pneumonia. The CBC shows a Hg 8 mg/dL, WBC 14, 000 cells/cm3 and

platelet count 70, 000 cells/cm3. The PTT is mildly prolonged, the fibrinogen level is decreased and fibrin split products

are present.

A 45 year old male undergoes abdominal exploration for blunt abdominal trauma. He has a shattered spleen and

undergoes splenectomy. Intraoperatively the anesthesiologist orders 2 units of packed red cells. During transfusion of

the second unit of packed red cells the anesthesiologist reports sudden changes in the vital signs. The temp is 102, P 120

and BP 96/60. The urine has a reddish color. You notice sudden diffuse hemorrhage from the entire peritoneal surface,

even from surfaces that are not directly injured.

A 25 year old morbidly obese female undergoes a laparoscopic cholecystectomy for chronic cholecystitis. In thepostoperative period she is on heparin 5000U SQ BID for deep venous thrombosis prophylaxis. On the second

postoperative day the patient complains of left leg swelling. The duplex venous sonogram reveals a deep venous

thrombus in the left common femoral vein. The patient receives therapeutic heparin therapy at 800 U/hr and the PTT

is 72 sec. On the second day of therapeutic heparin therapy the patients platelet count decreases from a preoperative

value of 220, 000 cells/mm3 to a postoperative value of 48, 000 cells/mm3 now.

A 57 year old male has received one cycle of chemotherapy for diffuse small cell lung cancer. He now presents to the

emergency department with acute mental status changes. The vital signs are temp 99, P 98, RR 22 and BP 140/90.

There are no focal neurologic deficits. A CT scan of the head reveals no metastatic lesions and no intracranial edema.

Serum chemistry reveals a Na 115 mEq/L and urine studies show specific gravity and urine osmolality are both

elevated.

A 20 year old male sustains a blow to the right side of his head with a blunt object during an altercation. A witness to

the altercation phones 911 and emergency technicians arrive within minutes. In the field the patient is combative so the

emergency technicians perform immediate orotracheal intubation with in line neck stabilization. They place two large

bore intravenous catheters in the upper extremities and administer Lactated Ringers solution 1 liter during transfer to

the Emergency Center at University Hospital. The vital signs are temp 99, P 120, RR 16, BP140/85, ht 73 inches,

wt 70 kg. He has a large abrasion over the right cerebral area. The right pupil is dilated compared to the left pupil. He

voluntarily moves his right upper extremity more than the left upper extremity. The CT scan of the head shows a right

epidural hematoma and he undergoes craniotomy with evacuation of the epidural hematoma. On the second

postoperative day the urine output is 500 cc/hr, the urine specific gravity is 1.001, the urine osmolality is 200

mOsm/L. The serum Na level is 158mEq/L.

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Week 2 Critical Care