Critical Care ABIM Certification Exam Review Course Leslie - PDF document

Critical Care ABIM Certification Exam Review Course Leslie Zimmerman, MD Professor of Clinical Medicine, UCSF ICU Director, SFVAMC Lecture Outline  Cardiopulmonary Failure  Sepsis/ARDS  GI issues  Odd and ends for $200 Question 1 A middle aged man collapses at the ballpark. He is unresponsive and has no pulse or respirations. Correct interventions include: A. Chest compressions alone at 100/minute B. Use of AED only by ACLS trained personnel C. 3 “stacked” shocks as soon as defibrillator is available D. Rapid ventilation (bag or mouth) 1

CPR and Defibrillation for Sudden Cardiac Death  Sudden cardiac death causes 300,000+ deaths/year  Strongly associated with coronary artery disease*  Despite the overall decrease in CV mortality, the proportion of cardiovascular death from sudden cardiac death has remained constant *Weaver WD, et al. Circulation. 1976;54:895-900. CPR and Defibrillation for Sudden Cardiac Death  Survival rates for out-of-hospital cardiac arrest vary from 5% to 18%, depending on the presenting rhythm  Early bystander CPR can double or triple the victim’s chance of survival  CPR plus defibrillation within 3 to 5 minutes of collapse can produce survival rates as high as 49% to 75% BLS 2013 A-B-C  C-A-B IF you want to check for pulse, limit to 10 seconds IF you are trained in rescue breaths: Chest compressions FIRST! then 2 breaths/ 30 compressions IF NOT, just give chest compressions! circ.ahajournals.org 2

CPR CPR: Hard and fast in middle of patient’s chest (between nipples) with minimal interruptions. Hand over heal. Adults: depress 2 inches (1/3 of AP diameter). Allow for complete recoil between. AT LEAST 100/minute. circ.ahajournals.org AHA motto: “Push Hard and Fast!” CPR If someone arrives trained to do rescue breaths, let them do rescue breaths No breathing  Open airway Still no breathing  2 breaths/ 30 compressions circ.ahajournals.org 2 nd person – asynchronous breaths 8-10/minute Mouth ‐ to ‐ mouth resuscitation? Hallstrom A , et al. NEJM 2000;342:1546-53. CPR by chest compression alone or with mouth-to- mouth ventilation.  911 randomized instructions to bystanders  Instructions for compressions-only required less time  Survival to hospital discharge among patients assigned to chest compressions-only was as good as full CPR (14.6% vs. 10.4%). 3

CPR ‐ AHA Recommendations  If a bystander is not trained in CPR, then the bystander should provide hands-only CPR  If bystander previously trained in CPR is confident in ability to provide rescue breaths with minimal interruptions in chest compressions, bystander should provide either conventional CPR using a 30:2 compression-to-ventilation ratio or hands-only CPR Mouth or bag ‐ mask…  May discourage bystanders from starting CPR  May interrupt good quality chest compressions  Can overinflate lungs and decrease venous return  At some point, you do need to start ventilation… AED Arrives circ.ahajournals.org 4

AED www.heartsmart-aed.com/ Philips -AED AED Open Put pads on chest Push On Follow Instructions It will advise shock and will charge for V www.laerdal.com/us/ tach & V fib, but not for Asystole or PEA AED Pads: apply to chest circ.ahajournals.org 5

AED Effective? Marenco JP JAMA. 2001;285:1193-200.  Use of AEDs by first responders and laypersons reduced time to defibrillation and improved survival from sudden cardiac arrest Question 1 A middle aged man collapses at the ballpark. He is unresponsive and has no pulse or respirations. Correct interventions include: A. Chest compressions alone at 100/minute B. Use of AED only by ACLS trained personnel C. 3 “stacked” shocks as soon as defibrillator is available One shock, CPR x 2 min, shock D. Rapid ventilation (bag or mouth) Too fast can decrease venous return Sequence: not drug then shock CPR Epi 2 minutes Shockable rhythm? Shock! 5 minutes 6

ACLS– Cutting Edge Use of in-line End tidal CO2 monitor: www.nonin.com More circulation, more CO2 delivered to lungs, more exhaled; first sign of ROSC Falling ET CO2, less circulation, tiring CPR performer, switch out ACLS– Cutting Edge Defib pads that tell you when CPR is inadequate! ACLS– Cutting Edge In hospital cardiac arrest: Goldberger ZD, et al. “Duration of Resuscitation Efforts and Survival after In-Hospital Cardiac Arrest: An Observational Study. Lancet 2012; 380:1473. • 80% PEA or asystole at presentation • ROSC 48% • 15% survived to discharge with good neurological recovery • The LONGER the resuscitative effort, the better the outcome in PEA arrest 7

Question 2 A 68 yo man with a history of smoking, HTN and DM presents to the ED with confusion, SOB, and increasing peripheral edema. Exam: BP 135/90 HR 110 Moderately obese, tired but oriented. Lungs with rales ½ up; rare wheezes. Cor: tachy without murmurs. 4+ edema to thighs. Labs: Hct 52% WBC: 22,000 BNP 900 BUN 28 Glucose 255 ABG: 7.30/ PaCO2 62/ PaO2 45 Question 2 CXR: Moderate cardiomegaly and vascular congestion. RX: O2, Diuretics, bronchodilators, antibiotics. He is still lethargic, but oriented. F/u ABG on 2 LPM O2: 7.29/ PaCO2 65/ PaO2 52 Question 2 68 yo, initial ABG: 7.30/ PaCO2 62/ PaO2 45 F/u ABG 2 LPM O2: 7.29/ PaCO2 65/ PaO2 52 Next, you should: A. Give sodium bicarbonate B. Increase O2 to 6 LPM C. Intubate patient and begin assist control ventilation D. Order sleep study E. Start noninvasive positive pressure ventilation 8

NiPPV Non-invasive Positive Pressure Ventilation  Ventilation without endotracheal tube or tracheostomy  Best in rapidly reversible conditions: CHF, COPD exacerbation, or post-extubation NiPPV The patient wears a tight-fitting mask which is connected to a CPAP, Bilevel PAP, or ventilator Patient gets larger tidal volume with same inspiratory effort. This improves PaCO2 & decreases work of breathing www.clevelandclinicmeded.com Why does it work? Oxygenation Work of Breathing  Decreases  Positive pressure microatelectasis counterbalances  Drives water out of inspiratory threshold alveoli related to intrinsic PEEP CO2 elimination  Reduction in inspiratory muscle work  Larger tidal volume  No ETT resistance load with same inspiratory effort  If ventilator, can add mandatory rate 9

Potential Disadvantages of NiPPV (vs. intubation)  System • Slower correction of gas exchange abnormalities • Increased initial time commitment (need 1:1 RT)  Mask • Air leakage  poor correction of gas exchange • Transient hypoxemia from accidental removal  Lack of airway access and protection • Suctioning of secretions harder Complications • Facial skin erythema/ skin breakdown #1 complication • Nasal congestion/nasal/oral dryness • Nasal bridge ulceration • Sinus/ear pain • Eye irritation • Gastric distension (< 2%) • Aspiration pneumonia • Poor control of secretions Good Bad Respiratory acidosis Secretions, low CO2, apnea CHF, COPD exacerbation, Severe encephalopathy, or post-extubation agitated or uncooperative Respiratory distress: High Aspiration risk, facial trauma or RR, accessory muscle use, facial or gastro-esophageal paradoxical breathing surgery Code blue, unstable hemodynamics or rhythm Example: Coughing up thick secretions, ABG 7.33/25/45  Secretions, hypoxic with metabolic acidosis  NiPPV ? NO!!! 10

NiPPV NiPPV- if going to work, should see improvement clinically and in PaCO2 within 2-3 hours. Key is the balance between avoiding intubation with risk of VAP vs. delay in necessary intubation (risk of cardiac ischemia) • COPD exacerbations: Decreased intubation, hospital length of stay, mortality.* • CHF: + pressure decreases pre-load. Decreased intubation** & mortality***. * Ram FS, et al. (Cochrane Review). Cochrane Database Syst Rev 2004; :CD004104. ** Gray A, et al. NEJM 2008;359:142. *** Masip J, et al. JAMA 2005; 294:3124. How to start?  Head of bed up 30+ degrees  RT able to be 1:1 with patient?  Select mask (fit small, medium, large)  Select machine  Oxygen to keep saturation > 90%  Start low IPAP 8-10; EPAP 5, then increase IPAP EPAP prevents early airway Drives TV closure increases FRC  Put mask up to patient’s face, few breaths, take off and reassure patient, place back on; patient can hold  Increase IPAP if needed to decrease dyspnea  Once settled, then add straps, check for leaks CPAP vs. BiPAP in CHF? Gray A, et al. NEJM 2008;359:142 CPAP BiPAP CHF  no clear advantage (patient tolerance) COPD  ventilation is an issue  BiPAP (+/- back-up rate). 11

NiPPV for Respiratory Failure Best mask?  Full face mask: Best physiologic and arterial blood gas improvement  Nasal mask: More comfortable, easier to cough up secretions, easier to speak  50% of those started on nasal mask have to be switched to full face mask Nasal Pillows Full Nasal Mask Full Face Mask Mask fits to: Bilevel PAP CPAP - Set two - Set one pressures: pressure: inspiratory & continuous CPAP or Full mode Ventilator expiratory - Any mode, but BiPAP +/- available usually Pressure Home use for OSA or chronic back-up rate; Support + CPAP; can hypoventilation cheaper than set back-up rate Limited or No display of vent numbers Check for Leaks  Look at patient  noisy leak?  Look at display and compare inspiratory tidal volume to expiratory tidal volume 12