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Serum Na+ Serum K+

2011/2012 Electrolye imbalance

(135-145 mmol/L) (3.5-5 mmol/L)

Types :-

( Evaluation of urinary Na+ (10-20 mmol/L) )

Hyponatremia (<135 mmol/L)

Clinical manifestations :-

Hypovolemic hyponatremia Urinary Na+ >20 due to renal loss (diuretics, hypoaldosteronism , RTA, renal disease) Urinary Na+ <10 due to extrarenal loss (vomiting ,diarrhea ,3rd space loss) Euvolemic hyponatremia Causes: cushing, hypothyroidism, drugs and SIADH Causes of SIADH: Cancer: lung ,pancreas Pulmonary lesions: pneumonia, lung abscess, T.B C.N.S. disorders: meningitis, encephalitis Hypervolemic hyponatremia Urinary Na+ >20 due to renal failure (ARF,CRF) Urinary Na+ <10 due to liver cirrhosis, congestive heart failure C.N.S. (brain oedema) : lethargy, apathy, convulsions Neuromuscular : muscle cramps, anorexia, nausea Acute symptoms within 48 hrs of onset (at more risk to develop brain oedema) Chronic : more time to adapt to changes, rapid correction center pontine myelenolysis Hypovolemic : Normal saline 0.9 % + fluid restriction Hypervolemic : hypertonic saline 3 % + diuretics Euvolemic : fluid restriction + diuretics

Treatment:-

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In general
Rate of correction : 2 mmol/hr till resolution of symptoms 3 % hypertonic saline Loop diuretics (frusemide) Fluid restriction TTT cause

Chronic hyponatremia (SIADH) Fluid restriction Loop diuretics Lithium Demeclocyclin Vasopressin antagonists

Hypernatremia (Na >145mmol/L)

Types :1-hypovolemic hypernatremia urinary Na+ >20 due to renal loss(diuretics) urinary Na+ <10 due to extra renal loss (Diarrhea or GIT fistula ) 2-euvolemic hypernatremia Diabetes insipidus 3-hypervolemic hypernatremia Conn's syndrome or cushing Replacement of ECV with : 0.9% saline if hypovolemic

Treatment :

0.45% saline or dextrose 5 % in H2O Dialysis to treat hypervolemia

Hypokalemia (k<3.5 mEq/L)

Causes:1. Intracellular shift : insulin, B2 agonist 2. Total body K+ according to urinary K+

3. >20mmol/L : renal loss (RTA, DKA, Diuretics) 4. <20mmol/L : GIT loss (diarrhea, vomiting)

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Clinical manifestations:Cardiac : digitalis toxicity, arrhythmia GIT : constipation, paralytic ileus Dietary K+ supply Muscular : cramps, weakness (flaccid paralysis)

Treatment :-

In life threat ( I.V KCL through central V.)

Hyperkalemia (>5 mEq/L)

Causes :1. Extracellular shift: metabolic acidosis, insulin, beta blockers 2. Renal excretion: RF, RTA Ascending paralysis (late) Fatal if >7.5

Clinical manifestations :-

Cardiac : ECG (hyperacute T wave, prolonged PR,QT,QRS), bradycardia,cardiac arrest

Treatment :-

Immediate : (ca gluconate 10 % (slow I.V) Insulin + glucose Long acting : frusemide Dietary K+ Dialysis in renal impairment B2 agonist inhalation

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Aetiology
N.B C.O= SV X HR Causes :

2011/2012 Shock

Hypovolemic, cardiogenic, extra cardiac obstructive, Distributive, Mixed.

1) Hypovolemic
Blood loss: trauma, GIT bleeding Vomiting, Diarrhea Blood transfusion Lactate ringer

TTT:

2) Cardiogenic
Causes: TTT:

Myocardiac infraction Arrythmia

3) Obstructive
Causes:

Dobamine Thrombolytics Levophed (Norepinephrine)

a) Preload: a. Tension pneumothorax b. Cardiac tamponade a. Pulmonary embolism b. Aortic dissection

b) Afterload:

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TTT:

2011/2012
Thrombolytics Anticoagulant e.g Heparin Vasopressor (For Pulmonary) (embolism)

4) Distributive:
Causes:

TTT:

Vasodilatation as in: Early sepsis Anaphylaxis Neurogenic

N.B:

i. ii. iii. iv. v. i. ii. iii. iv. v.

Eradication by antibiotic + Vasopressor Corticosteroids Antihistaminics

We cant depend on blood pressure as a measure for shock as it changes in late shock. Tachycardia is more important to be monitored during shock. All shock stages have low cardiac output except distributive. Vasodilators can be used in cardiogenic shock Cardiogenic shock CVP

CPR

Basic life support (BLS):

(30 compressions: 2 assisted breathing) i. Chest compression (30 compressions) ii. Airway: head tilt, chin lift (Jaw thrust in trauma) iii. Breathing: Ambu bag (2 puffs)

Ensure safety. Shake & Shout. Scan for breathing efforts for 5- 10 sec. Code blue & Get D.C. Feel the carotid pulse.

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Advanced cardiac life support ( ACLS

i. Chest compression ii. Oropharyngeal airway: endotracheal intubation (100/min compression continuous without interruption, air puff every 5-6 sec.) . Cardiac monitor Shockable rythms Ventriular Tac (vTac) Non-shockable Pulseless electrical activity

V.F

Asystole

TTT

-DC shock (CPR 30:2) -After 2 DC shock & no response Give 1 mg Adrenaline IV -After 3rd shock Give amiodarone bolus 300 mg IV

-CPR 30:2 -Adrenaline 1 mg -DC monitor

Reversible causes of pulseless elect activity:

4H :
1. 2. 3. 4. Hypoxia Hypothermia Hypovolemia Hypokalemia/ Hyperkalemia

4T:

1. Thrombosis (Massive pulmonary embolism) 2. Tension pneumothorax 3. Tamponade 4. Toxicity

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CPR done for 20 min.

Containdication:
-DNAR -Signs of irreversible death -No physiological benefit is expected -Advanced metastatic stage 4, Advanced AIDS.

Prognostic features:

Conscious level, babiniski sign, pupil reactivity, spontaneous movement.

Sepsis
SIRS: Stimulation of immune system due to any cause. Sepsis: SIRS due to a localized primary site of infection. Septic shock: sepsis + MOSF +Hypotension unresponsive to fluid replacement. Gram ve : E.cloi,proteus,klebsiella,pseudomonas. Gram +ve : staph.aureus, strept.pneum, enterococcus.
1. Extremes of age < 10 years & > 70 years. 2. previous antibiotic treatment 3. Invasive procedures. 1. From sepsis 15% 2. From septic shock 40-75 %

Risk factors:

Mortality in best centers:

when to suspect sepsis:

1. Temp. >38 C or < 36C 2. Tachycardia >90/min 3. Tachypnea > 20 1.
2.

Criteria of SIRS (presence of 2 or more)

3. 4. 5. -Paco2 <32 mmHg -WBCs <4000/mm3or >12000mm3 -Temp <36 or >38 -H.R >90 -R.R >20

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1. 2. 3. 4. 5. 6.

2011/2012

Management :

Mimics of sepsis :
1- Adrenal failure 2- Anaphylaxis 3- Pulmonary embolism 4- Acute pancreatitis 1. 2. 3. 4. 5.

Bed rest & ICU Proper antimicrobial Steroids & APC Empiric monotherapy : Carbepnem , piperacillin For urosepsis : Quinolones For IV line sepsis : Vancomycin

Monitoring of ICU patient

Temp: Pulse: RR:

Vital signs :

Conscious level ---- > Glascow coma scale Eye opening Verbal response Motor response Incubate the patient if < 8

normal : 36.5-37.2 Critical <35 or >40

normal : 60-100 Critical : <45 or >130 normal : 12-20 Critical : <10 or >26

O2 saturation: Bl.pr:

normal: 95-100 Critical: <90 systole: normal: 90-130 Critical: <80 or >200 Diastole: normal: 60-90 Critical: <55 or >120
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Respiratory failure

Minute ventilation = TV x RR

Laboratory diagnosis :
Pa O2 < 60 mm Hg Pa CO2 > 50 mm Hg Hypoventilation V/Q mismatch

Pathophysiology
Type I

TypeII
ventilation increase Pa CO2 hypercapnic decrease Pa O2 hypoxemic Causes: severe airway obstruction ( COPD , severe asthma ) brain stem & sp. cord diseases Musculoskeletal: Kyphoscoliosis Ankylosing spondylitis Neuromuscular: Guillian barre Myasthenia gravis

Oxygenation Decrease Pa O2 hypoxemic Normal or decrease Pa CO2 Causes: pneumonia (most important) pulmonary embolism cardiogenic pulmonary edema

Distinctions between acute & chronic :

1. bicarbonate concentration 2. polycythemia 3. corpulmonale

Manifestations: Hypoxemia

hypercapnea
Lethargy Headache slurred speech papilledema diaphoresis

Cyanosis Confusion Convulsions Coma Tachycardia/bradycardia Tachypnea Hypotension/hypertension

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Signs of respiratory distress :

1. tachypnea 2. tachycardia 3. working accessory muscles 4. pulsus paradoxus 5. paradoxical respiration

N.B:
Acute management of COPD : albuterol , ipratropium , methyl amoxicillin Acute respiratory failure in presence of: a. failure to correct hypoxia or hypercapnea b. tachypnea > 36/min c. coma d. hypotension/shock prednisolone,

Indications of mechanical ventilation:

Complications of mechanical ventilation :

a. b. c. d. e.

Diagnostic criteria of ARDS:

a. b. c. d.

complications of endotracheal intubation pneumonia lung injury barotrauma ( pneumothorax , pneumomediastinum ) volutrauma acute onset of respiratory distress severe hypoxemia ( gas exchange abnormality: Pa O2/FIO2 < 300 ) bilateral pulmonary infiltrate absence evidence for cardiogenic pulmonary oedema

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1. 2. 3. 4. 5.

2011/2012
Direct Indirect

Causes of ARDS ( non cardiogenic pulmonary oedema ) :

Pulmonary aspiration of gastric contents Near drowning Diffuse pneumonia Fat embolism Amniotic fluid embolism 1. 2. 3. 4. 5.

sepsis pancreatitis severe nonthoracic trauma severe burns DIC

N.B: types of mechanical ventilation :

invasive ( tracheal intubation ) non invasive ( face mask ) --- > CPAP: continuous expiratory --- > BIPAP: expiratory & inspiratory

PaO2 80-100 mm Hg SPO2 95-100% PaCO2 35-45 mm Hg HCO3 22-26 mmol/L PH 7.35-7.45 if PH < 7.35 ---- > acidosis -- HCO3 --- > metabolic ++ PaCO2 --- > respiratory

ABG

if PH > 7.45 --- > alkalosis

FiO2 is 21% in room air N.B:

++ HCO3 --- > metabolic -- PaCO2 --- > respiratory

significant changes of PH < 6.8 or > 7.8 may lead to death lung compensate for imbalance within 1-3 min.

1ry Disorder
Resp. Acidosis Resp. Alkalosis Metab. Acidosis Metab. Alkalosis

1ry change
++ PaCO2 --PaCO2 --HCO3 ++ HCO3

Compensation
++ HCO3 --HCO3 --PaCO2` ++ PaCO2

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N.B. :

2011/2012
pH & PaCO2 opposite in resp & same direction in metabolic Fully compensated >>>> pH is normal Partial compensated >>>> pH -- or ++ Causes of 1ry Hyperventilation : - Anxiety , pain or distress - Hypoxemia , fever - Salicylate toxicity Hyperventilation may occur secondary to metabolic acidosis

Causes of metabolic acidosis

Renal failure , DKA Shock , Starvation Salicylate toxicity Oxygen dissociation curve is shifted to : Right in acidosis , fever , ++ PaCO2 Left in alkalosis , hypothermia , -- PaCO2

Anion Gap = Na - ( Cl + HCO3 ) Or = Na + K - ( Cl + HCO3 )

N.B. :

Definition of O2 saturation : amount of O2 carrying hemoglobin in blood Definition of Shock : Tissue perfusion is inadequate to supply O2 & nutrients to body cells The commonest complications in ICU : sepsis & bed sores

++ Anion Gap : ( ++ acid production ) Lactic acidosis Ketoacidosis Intoxication ( aspirin , Methanol ) Normal anion gap : ( ++ HCO3 loss ) RTA Diarrhea Adrenal insufficiency

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1. ______________ 2. ______________ 3. ______________

2011/2012
Model 1(2012)

Mention three indications for mechanical ventilation:

Mention two complication of mechanical ventilation: 4. ______________ 5. ______________ Mention three causes of hyperkalemia: 6. ______________ 7. ______________ 8. ______________ Mention two drugs that can cause hypokalemia: 9. _____________ 10. ______________ Mention three causes of metabolic acidosis: 11. ______________ 12. ______________ 13. ______________ Mention two causes of metabolic alkalosis: 14. ______________ 15. ______________ Mention the normal values: 16. Serum sodium______________ 17. Serum potassium______________ 18. Serum bicarbonate______________ 19. Blood PH______________

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20. Arterial Blood oxygen saturation______________ 21. Partial pressure of CO2 in arterial blood______________ 22. Partial pressure of O2 in arterial blood______________ 23. Body temperature______________ 24. Respiratory Rate______________ 25. Pulse Rate______________ 26. You found a man lying on the ground and after finding him unresponsive with no breath movement next thing to do is ______________ & get a 27. ______________ 28. Acidosis shifts the oxyhb dissociation curve to the ____________ 29. What is the most imp complication in an ICU patient? ___________ 30. How can we prevent it? ____________ Fill in the blank with one of the words below O2 saturation Metabolic acidosis Respiratory failure 31. 32. 33. 34. 35. 36. Partial pressure of O2 Respiratory alkalosis Shock

______________is a disorder characterized by decrease in blood CO2 ______________is a disorder characterized by decrease in blood O2 ______________is a measure for oxygen carrying on hemoglobin. ______________is a disorder characterized by tissue hypoperfusion ______________is a disorder characterized by decrease in serum bicarbonate. ______________is a measure for oxygen dissolved in blood.

Describe the anatomical site for: 37. 38. 39. 40. 41. Cardiac massage:_________ Artery used to assess pulselessness if a patient collapses:____________ Assessment of central cyanosis:_____________ Assessment of peripheral cyanosis:_____________ Assessment of central venous pressure:_____________

Match column A with column B: 42. 43. 44. 45. 46. Heart rate in ventricular tachycardia Respiratory rate in ARDS Systolic blood pressure in shock Glascgow coma scale in deep coma Hypothermia <5 <36.5 <60 >250 >28

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47. 48. 49. 50. Hypovolemic Cardiogenic Anaphylactic Septic

2011/2012
Corticosteroids Inotropics Antimicrobials IV fluids

Match the following types of shock with their corresponding lines of treatment:

A 65 year old woman develops diffuse bilateral lung infiltration in chest x-ray after an episode of bacteremia related to a urinary tract infection. Her ABG analysis shows: pH 7.46, P aO2 54 mmHg, PCO2 21mmHg.She is intubated and placed on mechanical ventilation. 51. What is the type of respiratory failure she has? __________________ 52. the most likely cause in the above case_____________________

Mention whether each of the following parameters is expected to increase, decrease or is unchanged in the following situations: (8 marks) 1. 2. 3. 4. In type I respiratory failure PO2 ______________ while PCO2 _______________ In type II respiratory failure PO2 ______________ while PCO2 _______________ In metabolic acidosis HCO3 level is ______________while PCO2___________________ In respiratory acidosis HCO3 level is ______________while PCO2___________________

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Model 2 (2012)

1. You found a man lying on the ground and after finding him unresponsive with no breath movement next thing to do is ______________ & get a 2. __________________ 3. Acidosis shifts the oxyhb dissociation curve to the ____________ 4. What is the most imp complication in an ICU patient? ___________ 5. How can we prevent it?____________ Mention normal values: 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Serum Sodium:_______ Serum Potassium:_________ Serum HCO3:___________ pH:____________ Blood O2 Saturation:___________ Partial pressure of arterial CO2:___________ Partial pressure of arterial O2:__________ Temperature:_______________ Respiratory rate:_______________ Pulse:____________________

Fill in the blank with one of the words below Partial pressure of O2 Respiratory alkalosis Shock 16. 17. 18. 19. 20. 21. O2 saturation Metabolic acidosis Respiratory failure

______________is a disorder characterized by decrease in PCO2 ______________is a disorder characterized by decrease in PO2 ______________is a measure of O2 carrying on Hb. ______________is a disorder characterized by tissue hypoperfusion ______________is a disorder characterized by decrease HCO3 in the Blood ______________is a measure of O2 dissolved in the arterial blood

Describe the anatomical site for: 22. 23. 24. 25. 26. Cardiac massage:_________ Artery used to assess pulselessness:____________ Assessment of central cyanosis:_____________ Assessment of peripheral cyanosis:_____________ Assessment of central venous pressure:_____________ [Type text]

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Mention the three indications for mechanical ventilation: 27. _________________________________________ 28. ___________________________________________ 29. ____________________________________________ Mention two complications for mechanical ventilation: 30. _______________________________________ 31. ______________________________________ Mention whether the following parameters are increased, decreased or unchanged: 32. 33. 34. 35. 36. 37. 38. 39. In case of type I respiratory failure, PO2 ______________ & PCO2 _______________ In case of type II respiratory failure, PO2 ______________ & PCO2 _______________ In case of metabolic acidosis, HCO3 level is ______________& PCO2___________________ In case of respiratory acidosis, HCO3 level is ______________& PCO2___________________

2011/2012

Match column A with column B: 40. 41. 42. 43. 44. Heart rate in ventricular tachycardia Respiratory rate in ARDS Blood pressure in shock Glasgow coma scale in deep coma Hypothermia <5 <36.5 <60 >250 >28

Match type of shock with their specific treatment 45. 46. 47. 48. Hypovolemic Cardiogenic Anaphylactic Septic Corticosteroids Inotropes Antimicrobials IV fluid

A 65 year old woman develops diffuse infiltrations in the lungs in chest x-ray after an episode of bacteremia related to a urinary tract infection, after an ABG of pH 7.46, PO2 54, PCO2 21 the patient deteriorated and she was incubated and placed on mechanical ventilation. 49. What type of respiratory failure is this?__________________ 50. What is the most likely cause in the above case?_____________________

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