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Critical Care Medicine Review Notes CRITICAL CARE MEDICINE REVIEW NOTES Jon-Emile S. Kenny M.D. 2014 Critical Care Board Study Notes 2014 h 1 Esteemed reader, I compiled these notes while studying for the ABIM Critical Care Medicine Board examination. These notes were made from a number of fairly recent resources including SCCM lectures, SEEK questions, ACCP study guides and, of course, pulmccm.org. I cannot guarantee their correctness in content, grammar, and spelling; nor are these notes peer-reviewed. They absolutely should not be used as a resource for patient care. They should be used for board exam preparation; that is all I will use them for as well. This is not my heart-lung physiology text. Please share these review notes freely. #FOAMcc Happy Studies, Jon-Emile www.heart-lung.org JEK Critical Care Medicine Review Notes Critical Care Board Study Notes 2014 h 2 03 23 48 64 74 89 101 110 124 www.heart-lung.org JEK Critical Care Medicine Review Notes Critical Care Board Study Notes 2014 h 1. CRITICAL CARE CARDIOLOGY 3 CARDIAC RESUSCITATION account of the cold diuresis. There is an The quality of CPR is associated with survival to increased risk of infection following TH and discharge for in-house arrest. It is not the altered drug metabolism. application of an AED, which has been studied. 40% of chest compressions in house are of However, skeptics noted the lack of blinding to insufficient depth, there is a long period of time treatment allocation in the above studies. during codes when health care providers are not Further, in the biggest of those hypothermia actually on the chest. Compressions should be studies, a large number of patients in the usual hard and fast [to Bee Gee’s stay’n alive] 100 per care group developed fever which is associated minute, 2 inch depth. There should be with worse outcomes after cardiac arrest. So it minimization of time off the chest even for pulse was thought that perhaps TH simply had to checks and defibrillation. It is CPR that matters, 2 accomplish fever reduction to improve outcome. minutes of CPR interspersed with defibrillation, 1 So the big one came out in NEJM November 17, mg epinephrine every 3-5 minutes or 40 U of 2013 [950 patients in 3 years, 80% vfib, 12% vasopressin. Atropine is no longer a part of PEA. asystole, 8% PEA, and randomized the patients to Avoid hyperventilation as this can reduce celsius 33 or 36 ASAP for 28 hours and then fever cerebral perfusion via alkalemia and more reduction for 72 hours]. After 72 hours, a importantly cause dynamic hyperinflation. neurologist blinded to initial treatment allocation recommended withdrawal or continued care Previously, the brain injury [apoptosis, based on standardized criteria, with withdrawal excitability, edema, etc.] induced by ischemia re- recommended only for known predictors of a perfusion was thought to be treatable. The Feb. terrible outcome [e.g., refractory status 2002 NEJM article with 137 patients in each arm, epilepticus; Glasgow motor score 1-2 with enrolled witnessed, shockable cardiac arrest bilateral absence of N20 peak on median nerve patient s with ROSC but still not following SSEP]. CPC more than 2 or Rankin more than 3 commands. Patients were randomized to was defined as severe disability. There was no therapeutic hypothermia target 32 to 34 celsius difference in death or disability between the two over 8 hours, held at that temp for 24 hours and groups [i.e. 33 versus 36 degrees] even in the 80% then passively re-warmed over 8 hours. A meta- shockable group. analysis of the three largest trials [380 patients] showed an odds ratio of 1.7 for favourable Temperature should be maintained at 36° C or neurological outcome. The largest of the three below after out-of-hospital cardiac arrest. trials selected patients who were resuscitated Despite its physiologic rationale and evidence of within 60 minutes with a shockable rhythm, benefit in prior smaller studies, targeted comatose, and not in shock. Cooling was done temperature management below 36° probably within 2 hours of the event. does not improve outcomes after out-of-hospital cardiac arrest of any type. Because average Therapeutic hypothermia [TH] is commonly human core temperature is 37° C, maintaining associated with coagulopathy, hyperglycemia, temperature continuously at or below 36° C still bradycardia and hypovolemia – the latter on would require cooling in almost all patients. www.heart-lung.org JEK Critical Care Medicine Review Notes Critical Care Board Study Notes 2014 h In a related vein, in 2013 JAMA, 100 patients with prior to the arrest was a major discriminator in 4 bacterial meningitis were randomized to 32-34 outcome: degrees or standard care and this trial was Only 10% of patients on pressors prior to arrest stopped early for a 20% absolute risk increase in survived to discharge, and only 4% overall were mortality! discharged home [the others went to rehab or What about the prognosis following cardiac long-term acute care]. arrest? What is the false positive rate for Among those with PEA/asystole despite pressors, diagnosis of poor neurological outcome? We only 1.7% were able to perform their own should strive for zero. Pupillary reaction to light activities of daily living at the time of discharge. has a false positive rate of 0-31% at day one. At day three, no pupillary reaction has a false People with ventricular fibrillation or tachycardia positive rate for poor outcome of zero. So absent not requiring pressors prior to arrest did much pupillary response at day three is important better: 40% survived, 20% went home, and information. The absence of corneal reflex is 17% had good neuro outcomes. similar at 72 hours. What about posturing? Similar at 72 hours. All of this data was CONGESTIVE HEART FAILURE generated during an era of no therapeutic hypothermia and the reason why neurological About 50% of the mortality with heart failure is assessment for continued care in the sudden, the other half is slow progression. There aforementioned trial took place at 72 hours. are stages of heart failure described in 2001 [ACC/AHA] where stage A is those patients at So what has a perfect specificity for determining risk, B [structural disease without symptoms] is poor neurological outcome? There is a review in NYHA I, stage C [current or prior symptoms] the Lancet – day 3 absent motor, absent pupillary corresponds to NYHA II and III and stage D is response and abnormalities in somatosensory NYHA IV. evoked potentials. SSEP occurs when the median nerve is stimulated. Bilateral absence is poor NYHA Class IV heart failure has a 60% mortality at neurological prognosis from NEJM article in 2009. one year. In acute, severe heart failure a poor Day 1-3 there is nothing great to help. You must prognosticator is: hypotension. Hypernatremia wait at least 72 hours and you must wait for and polycythemia are not. Hypotension is analgesia to wear off. This is important with TH defined as a systolic below 115 mmHg. Other because there is alteration of sedation and bad prognoses: hyponatremia, CAD, high BUN or analgesia metabolism with hypothermia – it will creatinine, low EF, elevated BNP or troponin, stay longer. There is no clear answer as to when anemia, diabetes. the patient may wake up, but anecdotally up to Precipitants of ADHF? 25% excess salt and fluid one week as the effects of hypothermia wear off intake, 25% noncompliance with medications, and sedation is cleared, though this will be less and 16% from adverse medication effects [e.g. important as TH is used less with the results of new CCB, NSAID, steroids, glitazones and ethanol, the Nov. 2013 NEJM trial. new anti-arrhythmics]. The rest are acute Prognosis after a first cardiac arrest occurring in medical causes such as ischemia, PE, HTN, valve the ICU is poor. An observational study of almost dysfunction, arrhythmia. There are extra-cardiac 50,000 such arrests showed an overall survival to causes as well – sepsis, infection, renal failure, hospital discharge of 16%. Requiring vasopressors thyroid, new anemia. www.heart-lung.org JEK Critical Care Medicine Review Notes Critical Care Board Study Notes 2014 h FLAVORS OF MYOCARDIAL DYSFUNCTION exercise tolerance, cardiac performance and 5 maybe survival. There are different kinds of myocardial dysfunction to consider – hibernating, stunned With myocarditis, patients typically get better myocardium, sepsis, myocarditis, etc. Stunned themselves, not good data but prednisone likely myocardium occurs when there is ischemia that improves EF by 5% but only if there is cellular relates to a wall motion abnormality, but when infiltrate on biopsy. There is improved exercise blood flow resumes, there is a persistent WMA tolerance and cardiac performance. that lasts from hours to days. The patient must TREATMENT MODALITIES FOR HEART FAILURE be supported during these time – consider stress cardiomyopathy as an example of stunned Treatment should improve quality & quantity of myocardium. The patient may present with all life; some meds do one or the other or both. the signs and symptoms of ischemia and heart failure with stress cardiomyopathy. There must What about diuretics? There is no difference in be no coronary stenosis to explain the disease continuous infusion versus bolus - Felker et al in and WMA do not correspond to single coronary NEJM 2011 [DOSE trial]. However high dose distribution. There may be STE and big T wave seemed to improve global assessment of inversions. symptoms – high dose is double their outpatient dose. There was no difference in creatinine, Recognize Takotsubo cardiomyopathy – the readmission, no cardiac performance change, major complications of this are mechanical in there is no survival benefit shown. nature, heart failure, shock and arrhythmia.
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