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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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Bonus MCQ Answers
MCQ 22 - Answer: A. CHADS0. Symptoms >48h so need to either do TEE then cardiovert
OR anticoagulated 3 weeks then cardiovert. After cardioversion must remain on OAC 4
weeks.
MCQ 23 – C is best answer…Type B Dissection due to Cocaine = medical managementà =
control HR first, but avoid beta blocker (cocaine)
MCQ 24 – B. Purposefully tricky question. Young man w dilated cardiomyopathy, ECG w
large 1o AVB and LBBB, consider differential ischemic and non ischemic causes (?sarcoid).
Beta blocker may be risky up front. Ivabradine doesn’t cause AV conduction delay but
not indicated here w HR <70. = Get cardiac MRI NOW
MCQ #25: ANSWER C (routine stress testing post PCI does not show any benefit per the POSTPCI trial. SGLT2 inhibition would be indicated given CAD + diabetes and would improve
outcomes. Flu shot per IAMI and polypill per the SECURE trial would also show benefit).
MCQ #26: Answer C – given this is a NSTEMI with LVEF >40%, he can drive privately from 2
weeks, commercially 1 mo, per new CCS 2023 Fitness to drive guidelines. If he had an LVEF 40%
or less, then D would be correct. If he was managed medically without PCI done, then D would
also be correct.
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Bonus MCQ Answers
MCQ #27: Answer B – PCI will not reduce CV mortality or dec hosp; and the recent REVIVED-BCIS trial demonstrated the lack of benefit
in multivessel PCI even if there was viability as in this patient. CABG based on the follow-up from the STICH trial, which showed CABG in a
patient with an ischemic cardiomyopathy like this, had benefits on reducing all cause and CV mortality, hospitalization. SGLT2i addition
and/or changing valsartan to sacubitril-valsartan would also carry benefit based on EMPEROR-Reduced, PARADIGM-HF trials etc.
MCQ #28: Answer D – this patient has an indication for anticoagulation with a CHADS65 score of 3. Ticagrelor with a DOAC is a
combination generally avoided due to higher bleeding risk, therefore ticagrelor should be changed to clopidogrel (A, B wrong). In the
setting of a DES placed 3 months ago for an MI, a dual pathway strategy would be preferred to complete 12 months of therapy with
clopidogrel + rivaroxaban (C wrong, D right) after which rivaroxaban would be indicated alone back at the full dose of 20mg!
MCQ #29: Answer A - Given a history of CAD and HF with LVEF >40%, antiarrhythmic options are limited to sotalol or amiodarone.
Sotalol would be the preferred option to try as he is young and amiodarone will have cumulative side effects. Stop bisoprolol if starting
another beta blocker; propafenone, flecainide and dronedarone are not appropriate in a patient with heart failure. Amiodarone could be
considered for this patient with CAD and HF but is not a great long term solution due to side effects).
MCQ #30: Answer D - PER NEW CCS 2022 PAD GUIDELINES, DO NOT SCREEN ASYMPTOMATIC PTS FOR CAD/CAS
MCQ #31: Answer: A. Patients with vasovagal syncope, even recurrent episodes, have low of episodes while driving, therefore no driving
restriction. Note if B was changed to have an avoidable trigger, like micturition syncope, this would have the same recommendation. The
CCS 2020 syncope guidelines and CCS 2023 Fitness to Drive guidelines do not specify what is needed to diagnose unexplained syncope.
The minimum work-up is history, examination and ECG followed by targeted investigations.
MCQ #32: Answer C. Aspirin should be continued to day of surgery, while ticagrelor should be held 2-3 days before, clopidogrel 2-7 days
before. DAPT is now (weakly) routinely recommended post CABG. Loading on DAPT for elective coronary angiography is not routinely
recommended as this could delay timing of a CABG due to bleeding risk.
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Critical Care Medicine & Toxicology
Saturday, December 2, 2023
Dr. Jacob Michie
www.internalmedicinereview.ca
© Internal Medicine Review 2024
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Acronyms Used in this Talk
• ABG – arterial blood gas
• Abs - antibodies
• ACS-Acute coronary syndrome
• AE - adverse events
• AG – anion gap
• AGMP-Aerosol generating medical procedure
• AKI-Acute kidney injury
• ARDS-Acute Respiratory Distress Syndrome
• A&O-Alert and oriented
• AVM – arteriovenous malformation
• b/l-Baseline
• BIPAP-Bilevel positive airway pressure
• BG-Blood glucose
• BP-Blood pressure
• CAM – confusion assessment method
• CCCS – Canadian Critical Care Society
• CI - Contraindication
• CO-Cardiac output
• COT-Conventional oxygen therapy
• CPAP-Continuous positive airway pressure
• CVP-Central venous pressure
• Ecmo-Extracorporeal Membrane Oxygenation
• ED-Emergency department
• EPAP-Expiratory positive airway pressure
• ETOH - ethanol
• ETT-Endotracheal tube
• EVD – external ventricular drain
• FiO2 – fraction of inspired oxygen
• FRC-Functional residual capacity
• GCS-Glascow coma scale
• HFNC-High flow nasal cannula
• HR-Heart rate
• ICP – intracranial pressure
• ICU-Intensive care unit
• IFN - Interferon
• ILD – interstitial lung disease
• IPAP-Inspiratory positive airway pressure
• IMV-Invasive Mechanical Ventilation
• iNO-Inhaled nitric oxide
• IVC-Inferior vena cava
• I:E-Inspiratory Time to Expiratory Time Ratio
• JVP-Jugular venous pressure
• LOC-Level of consciousness
• LR-Likelihood ratio
• LV-Left ventricle
• MAP-Mean arterial pressure
• NAC - N-Acetylcysteine
• MEWS – Modified early warning score
• NEWS – National early warning score
• MG – myasthenia gravis
• NDD-Neurologic Determination of Death
• NIV-Non-invasive ventilation
• NMBA-Neuromuscular blocking agent
• NS-Normal Saline
• NYD-Not yet diagnosed
• OG – osmolar gap
• OSA – obstructive sleep apnea
• OHS – obesity hypoventilation syndrome
• Pplat-Plateau pressure
• PEEP-Positive end expiratory pressure
• PIP-Peak inspiratory pressure
2
• PPE-Personal protective equipment
• PSILI – patient self induced lung injury
• PSV-pressure support ventilation
• RASS – Richmond agitation-sedation scale
• RM – Rumack-Matthew
• RCT – randomized control trial
• RL-Ringer’s lactate
• ROSC – return of spontaneous circulation
• RR-Respiratory Rate
• RSBI-Rapid shallow breathing index
• qSOFA-quick Sequential Organ Failure Assessment
• SBT-Spontaneous breathing trial
• SCC-Surviving Sepsis Campaign
• SIRS-Systemic Inflammatory Response Syndrome
• SUP-Stress Ulcer Prophylaxis
• SV-Stroke volume
• SVR-Systemic vascular resistance
• Sx-Surgery
• TFB – total fluid balance
• TCA-Tricyclic Antidepressant
• VBG – venous blood gas
• VF – ventricular fibrillation
• VT – ventricular tachycardia
• VTE-Venous thromboembolism
• Vt-Tidal volume
• VILI – ventilator induced lung injury
• V/Q-Ventilation/perfusion
BONUS
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OUTLINE
• Shock and Sepsis
• Respiratory failure
• Covid-19 in the Critically Ill
• Weaning from Mechanical Ventilation
• ICU Delirium, Sedation, Analgesia,
Sleep
• Targeted temperature management,
neuroprognostication, DNC, neuro
ICU
• Toxicology
• Extra slides for your reference:
– Acute hypoxia in the ICU
– Gas trapping
– Maternal cardiac arrest
– Liver failure guidelines
– Hyperthermia & Hypothermia
– Toxic ol og y Bo nus Sl id es
– Bonus MCQs
Useful Resources!
• https://sccm.org/Home
• https://emcrit.org/category/emcrit/
• https://litfl.com/
• https://oncicu.com/Home
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MCQ 1
2024
A 45y patient presents to the emergency department with a 2 day history of right upper quadrant abdominal pain,
fever, rigors and vomiting.
Initial vitals BP 79/50, HR 110, RR 26, SpO2 96% on RA, Temp 39.5C. Weight 70kg.
Exam: abdominal tenderness in right upper quadrant but no signs of peritonitis, capillary refill time is prolonged.
Laboratory : Hb 95, WBC 21, Plt 46, ALT 80, ALP 500, Bilirubin 50, Lactate 5.
Abdominal ultrasound in the ED shows a hypoechoic structure in the common bile duct with biliary dilation, and a
distended gall bladder with edematous walls.
Treatment: Two large bore antecubital fossa peripheral intravenous lines are inserted, broad spectrum antibiotics
and 3L of balanced crystalloid are administered.
Subsequent vital signs are BP 80/50 (MAP 60), HR 80, RR 24, SpO2 94% RA, POCUS shows a distended IVC without
respiratory variability, lactate is now 3.
What is the next best step in this patient’s management?
1. Consult Interventional Radiology for consideration of biliary drainage
2. Start hydrocortisone IV 200mg/day in divided doses
3. Start norepinephrine infusion via peripheral intravenous line
4. Transfuse platelets and insert a central venous catheter
5. Change MAP target to ≥ 60
4
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Circulatory Shock Syndromes
Distributive Hypovolemic Cardiogenic Obstructive
Loss of Vascular Tone Low Pre-load PUMP failure Excessive After-load
-
Sepsis
-
Anaphylaxis
-
SIRS (eg. pancreatitis)
-
Mitochondrial Dysf.
(eg. cyanide)
-
Endocrine (thyroid,
adrenal crisis)
-
Others*
-
Hemorrhage
-
Trauma
-
Burns
-
Operative losses
-
GI losses
-
Renal losses
-
Third space losses
(Pancreatitis)
-
ACS
-
Arrythmia
-
Acute Valvulopathy
-
Cardiomyopathy
(restrictive or dilated)
-
Right or left sided
heart failure
-
Pulmonary Embolism
-
Tam pon ad e
-
Ten sion
pneumothorax
66% 16% 16% 2%
5
Vincent and De Backer. Circulatory Shock. N Engl J Med 2013; 369:1726-1734
*Other Distributive: HLH, medications, liver failure, post cardiopulmonary bypass vasoplegia, neurogenic shock
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Sepsis Defined
(Surviving Sepsis Campaign, SCCM 2021)
“Life threatening organ dysfunction
secondary to dysregulated host response
to infection”
Use your clinical acumen, measure lactate,
and a screening tool to diagnosis sepsis
Septic Shock = Sepsis +
ü adequate volume resuscitation
ü Persistent ↓BP requiring
vasopressors to keep MAP ≥ 65
ü lactate > 2 mmol/L
6
Screening Tools recommended by SCCM
SIRS, MEWS, NEWS (not qSOFA)
SIRS is easiest tool to memorise for oral exam :
HR >90
Temp >38 or <36
RR >20 or PaCO2 <32
WBC >12 or <4 or 10% bands
2 or more = positive screen
LACTATE is helpful
but cannot rely on exclusively
Sensitivity (83%)
Specificity (85%)
Positive LR (LR 4.75)
Negative LR (LR 0.29)
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A quick word on differentiation of
cardiogenic vs septic shock
7
Central
Venous Gas
(ScvO
2
)
Mixed Venous
Gas
(SvO
2
)
Draw from
IJ Central Line
Pulmonary
Artery
Catheter
Contains
blood from
SVC SVC and IVC
Normal
O
2
fraction
60-65%
65-70%
• ScvO2 helps differentiate
cardiogenic vs septic shock
• > 80% corresponds with high
flow states (eg. sepsis).
Mitochondrial dysfunction
leads to reduced O
2
utilization
• < 65% indicates poor forward
flow: cardiogenic shock
• Here, the heart isn’t strong
enough to pump the
oxygen out to the cells
BONUS
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Sepsis: IMMEDIATE Initial Resuscitation
• If sepsis induced hypotension/shock, begin rapid administration of at least
30ml/kg
(ideal body weight) crystalloid within the first 3h (2021 = Suggestion)
• See next slide for guiding fluid resuscitation
• Use vasopressors if patient is hypotensive during or after fluid resuscitation
to keep MAP≥65
– Norepinephrine (“levophed”) is first line vasopressor
• Give broad spectrum antibiotics within 1 hour
– Obtain blood cultures prior to antibiotics if possible
• If ICU level care needed, admit to ICU within 6 hours
1. Evans et al. Critical Care Medicine 2021;
doi:
10.1097/CCM.0000000000005337
Diagnosis of Sepsis unclear?
DO : re-evaluate, perform
diagnostic tests, can delay antibiotic
start up to 3 h
DON’T : measure procalcitonin to
help with decision to start antibiotics
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